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 DSM-5 classification (e.g., passive-aggressive personality disorder).
The personality disorders are grouped into three clusters based on descriptive similarities.
Cluster A includes paranoid, schizoid, and schizotypal personality disorders. Individuals with
these disorders often appear odd or eccentric. Cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders. Individuals with these disorders often appear dramatic, emotional, or erratic. Cluster C includes avoidant, dependent, and obsessivecompulsive 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. Prevalence estimates for the different clusters suggest 5.7% for disorders in Cluster A, 1.5% for disorders in Cluster B, 6.0% for disorders in Cluster C, and
9.1% for any personality disorder, indicating frequent co-occurrence of disorders from different 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 personality disorder.
Dimensional Models for Personality Disorders
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. See Section III for a full description of a dimensional model for personality disorders. The DSM-IV personality disorder clusters (i.e., odd-eccentric, dramaticemotional, and anxious-fearful) may also be viewed as dimensions representing spectra of
personality dysfunction on a continuum with other mental disorders. The alternative dimensional models have 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.
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 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 cf long duration, and Its onset can be traced back at least to
adolescence or early adulthood.
E. The enduring pattern is not better explained as a manifestation or consequence of another mental disorder.
F. The enduring pattern is not attributable to the physiological effects of a substance (e.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 environment 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 functional impairment or 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 explained as a
manifestation or consequence of another mental disorder (Criterion E) and is not attributable to the physiological effects of a substance (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 personality disorders included in this chapter.
The diagnosis of personality disorders requires an evaluation of the individual's longterm 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., bipolar, depressive, 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 individual 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.
Deveiopment and 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., obsessivecompulsive and schizotypal personality disorders).
Personality disorder categories may be applied with 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 another mental disorder. It should be recognized that the traits of a personality 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 features must have been present for at least 1 year. The one exception to this is antisocial per-
sonality disorder, which cannot be diagnosed in individuals younger than 18 years. 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 another medical condition or an unrecognized substance use disorder.
Culture-Related Diagnostic Issues
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. It is useful for
the clinician, especially when evaluating someone from a different background, to obtain additional information from informants who are familiar 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 disorders) are diagnosed more frequently 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 underdiagnose certain personality disorders in females or
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 personality disorders describe features (e.g., suspiciousness, dependency, insensitivity) that
are also characteristic of episodes of other mental disorders. A personality disorder should
be diagnosed only when ihe defining characteristics appeared before early adulthood, are
typical of the individual's long-term functioning, and do not occur exclusively during an
episode of another mental disorder. It may be particularly difficult (and not particularly
useful) to distinguish personality disorders from persistent mental disorders such as persistent depressive disorder that have an early onset and an enduring, relatively stable
course. Some personality disorders may have a "spectrum" relationship to other mental
disorders (e.g., schizotypal personality disorder with schizophrenia; avoidant personality
disorder with social anxiety disorder [social phobia]) based on phenomenological or biological similarities or familial aggregation.
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.
Psychotic disorders. 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 bipolar or depressive disorder with psychotic features, or another psychotic disorder. When an individual has a persistent mental disorder (e.g., schizophrenia)
that was preceded by a preexisting personality disorder, the personality disorder should
also be recorded, followed by "premorbid" in parentheses.
Anxiety and depressive disorders. The clinician must be cautious in diagnosing personality disorders during an episode of a depressive disorder or an anxiety disorder, be-
cause these conditions may have cross-sectional symptom features that mimic personality
traits and may m^ke 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 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 substance use (e.g., antisocial behavior).
Personality change due to another medical condition. When enduring changes in personality arise as a result of the physiological effects of another medical condition (e.g.,
brain tumor), a diagnosis of personality change 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 nfiotives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, 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.
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 others 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 paranoid personality disorder is a pattern of pervasive distrust
and suspiciousness of others such that their motives are interpreted as malevolent. This
pattern begins by early adulthood and is present in a variety of contexts.
Individuals with this disorder assume that other people will exploit, harm, or deceive
them, even if no evidence exists to support this expectation (Criterion Al). They suspect on
the basis of little or no evidence that others are plotting against them and may attack them
suddenly, at any time and without reason. They often feel that they have been deeply and
irreversibly injured by another person or persons even when there is no objective evidence
for this. They are preoccupied with unjustified doubts about the loyalty or trustworthiness
of their friends and associates, whose actions are minutely scrutinized for evidence of hostile intentions (Criterion A2). Any perceived deviation from trustworthiness or loyalty
serves to support their underlying assumptions. They are so amazed when a friend or associate shows loyalty that they cannot trust or believe it. If they get into trouble, they expect that friends and associates will either attack or ignore them.
Individuals with paranoid personality disorder are reluctant to confide in or become
close to others because they fear that the information they share will be used against them
(Criterion A3). They may refuse to answer personal questions, saying that the information
is "nobody's business." They read hidden meanings that are demeaning and threatening
into benign remarks or events (Criterion A4). For example, an individual with this disorder may misinterpret an honest mistake by a store clerk as a deliberate attempt to shortchange, or view a casual humorous remark by a co-worker as a serious character attack.
Compliments are often misinterpreted (e.g., a compliment on a new acquisition is misinterpreted as a criticism for selfishness; a compliment on an accomplishment is misinterpreted as an attempt to coerce more and better performance). They may view an offer of
help as a criticism that they are not doing well enough on their own.
Individuals with this disorder persistently bear grudges and are unwilling to forgive
the insults, injuries, or slights that they think they have received (Criterion A5). Minor
slights arouse major hostility, and the hostile feelings persist for a long time. Because they
are constantly vigilant to the harmful intentions of others, they very often feel that their
character or reputation has been attacked or that they have been slighted in some other
way. They are quick to counterattack and react with anger to perceived insults (Criterion
A6). Individuals with this disorder may be pathologically jealous, often suspecting that
their spouse or sexual partner is unfaithful without any adequate justification (Criterion
A7). They may gather trivial and circumstantial "evidence" to support their jealous beliefs.
They want to maintain complete control of intimate relationships to avoid being betrayed
and may constantly question and challenge the whereabouts, actions, intentions, and fidelity of their spouse or partner.
Paranoid personality disorder should not be diagnosed if the pattern of behavior occurs exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder, or if it is attributable to the
physiological effects of a neurological (e.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 relationships. Their excessive suspiciousness and hostility may be expressed in overt argumentativeness, in recurrent complaining, or by quiet,
apparently hostile aloofness. Because they are 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
more often display a labile range of affect, with hostile, stubborn, and sarcastic expressions
predominating. Their combative and suspicious nature may elicit a hostile response in
others, which then serves to confirm 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
have a high degree of control over those around them. They are often rigid, critical of others, and unable to collaborate, although they have great difficulty accepting criticism themselves. 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 negative notions regarding people or situations they encounter,
attributing malevolent motivations to others that are projections of their own fears. They
may exhibit thinly hidden, unrealistic grandiose 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 may be perceived as "fanatics"
and form tightly knit "cults" or groups with others who share their paranoid belief systems.
Particularly in response to stress, individuals with this disorder may experience very
brief psychotic episodes (lasting minutes to hours). In some instances, paranoid personality disorder may appear as the premorbid antecedent of delusional disorder or schizophrenia. Individuals with paranoid personality disorder may develop major depressive
disorder and may be at increased risk for agoraphobia and obsessive-compulsive disorder. Alcohol and other substance use disorders frequently occur. The most common cooccurring personality disorders appear to be schizotypal, schizoid, narcissistic, avoidant,
and borderline.
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, hypersensitivity, peculiar thoughts and language, and idiosyncratic fantasies. These children
may appear to be "odd" or "eccentric" and attract 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 paranoid personality disorder in relatives of probands with schizophrenia and for a more specific 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 even be reinforced by the process of clinical
evaluation. Members of minority groups, immigrants, 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 regulations) or in response to the perceived neglect or indifference of the majority society. These
behaviors can, in turn, generate anger and frustration in those who deal with these individuals, thus setting up a vicious cycle of mutual mistrust, which should not be confused
with paranoid personality disorder. Some ethnic groups also display culturally related behaviors that can be misinterpreted as paranoid.
Differential Diagnosis
Other mental disorders with psychotic symptoms. Paranoid personality disorder can
be distinguished from delusional disorder, persecutory type; schizophrenia; and a bipolar or
depressive disorder with psychotic features because these disorders are all characterized by a
period of persistent psychotic symptoms (e.g., delusions and hallucinations). For an additional
diagnosis of paranoid personality disorder to be given, the personality disorder must have
been present before the onset of psychotic symptoms and must persist when the psychotic
symptoms are in remission. When an individual has another persistent mental disorder (e.g.,
schizophrenia) that was preceded by paranoid personality disorder, paranoid personality disorder should also be recorded, followed by "premorbid" in parentheses.
Personality change due to another medical condition. Paranoid personality disorder
must be distinguished from personality change due to another medical condition, in
which the traits that emerge are attributable to the direct effects of another medical condition on the central nervous system.
Substance use disorders. Paranoid personality disorder must be distinguished from
symptoms that may develop in association with persistent substance use.
Paranoid traits associated with physical handicaps. The disorder must also be distinguished from paranoid traits associated with the development of physical handicaps (e.g.,
a hearing impairment).
Other personality disorders and personality traits. Other personality disorders may be
confused with paranoid personality disorder because they have certain features in common.
It is therefore important to distinguish among these disorders based on differences in their
characteristic features. However, if an individual has personality features that meet criteria
for one or more personality disorders in addition to paranoid personality disorder, all can be
diagnosed. Paranoid personality disorder and schizotypal personality disorder share the
traits of suspiciousness, interpersonal aloofness, and paranoid ideation, but schizotypal personality disorder also includes symptoms such as magical thinking, unusual perceptual experiences, and odd thinking and speech. Individuals with behaviors that meet criteria for
schizoid personality disorder are often perceived as strange, eccentric, cold, and aloof, but
they do not usually have prominent paranoid ideation. The tendency of individuals with
paranoid personality disorder to react to minor stimuli with anger is also seen in borderline
and histrionic personality disorders. However, these disorders are not necessarily associated with pervasive suspiciousness. People with avoidant personality disorder may also be
reluctant to confide in others, but more from fear of being embarrassed or found inadequate
than from fear of others' malicious intent. Although antisocial behavior may be present in
some individuals with paranoid personality disorder, it is not usually motivated by a desire
for personal gain or to exploit others as in antisocial personality disorder, but rather is more
often attributable to a desire for revenge. Individuals with narcissistic personality disorder
may occasionally display suspiciousness, social withdrawal, or alienation, but this derives
primarily from fears of having their imperfections or flaws revealed.
Paranoid traits may be adaptive, particularly in threatening environments. Paranoid
personality disorder should be diagnosed only when these traits are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress.
Schizoid Personality Disorder
Diagnostic Criteria 301.20 (F60.1)
A. A pervasive pattern of detachment from social relationships and a restricted range of
expression of emotions in interpersonal settings, beginning by early adulthood and
present in a variety of contexts, as indicated by four (or more) of the following:
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. Tal<es 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., “schizoid personality disorder (premorbid).”
Diagnostic Features
The essential feature of schizoid personality disorder is a pervasive pattern of detachment
from social relationships and a restricted range of expression of emotions in interpersonal
settings. This pattern begins by early adulthood and is present in a variety of contexts.
Individuals with schizoid personality disorder 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 Al). They
prefer spending time by themselves, rather than being with other people. They often appear to be socially isolated or "loners" and almost always choose solitary activities or hobbies that do not include interaction with others (Criterion A2). They prefer mechanical or
abstract tasks, such as computer or mathematical 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 sensory, bodily, or interpersonal experiences, 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 disorder 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 normal subtleties of social interaction and often do not respond appropriately to social cues so that they seem socially inept or superficial and self-absorbed. They usually display a "bland" exterior without visible emotional
reactivity and rarely reciprocate gestures or facial expressions, such as smiles or nods (Criterion A7). They claim that they rarely experience strong emotions such as anger and joy.
They often display a constricted affect and appear cold and aloof. However, in those very
unusual circumstances in which these individuals become at least temporarily comfortable in revealing themselves, they may acknowledge having painful feelings, particularly
related to social interactions.
Schizoid personality disorder should not be diagnosed if the pattern of behavior occurs
exclusively during the course of schizophrenia, a bipolar or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder, 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 schizoid personality disorder may have particular difficulty expressing
anger, even in response to direct provocation, which contributes to the impression that
they lack emotion. Their lives sometimes seem directionless, and they may appear to
"drift" in their goals. Such individuals often react passively to adverse circumstances and
have difficulty responding appropriately to important life events. Because of their lack of
social skills and lack of desire for sexual experiences, individuals with this disorder have
few friendships, date infrequently, 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 under conditions of social isolation. Particularly in response to stress, individuals with this disorder may experience very brief psychotic episodes (lasting minutes to hours). In some instances, schizoid personality
disorder may appear as the premorbid antecedent of delusional disorder or schizophrenia. Individuals with this disorder may sometimes develop major depressive disorder.
Schizoid personality disorder most often co-occurs with schizotypal, paranoid, and avoidant personality disorders.
Prevalence
Schizoid personality disorder is uncommon in clinical settings. A prevalence estimate for
schizoid personality based on a probability subsample from Part II of the National Comorbidity Survey Replication suggests a prevalence 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 prevalence in the relatives of individuals with schizophrenia or schizotypal personality disorder.
Culture-Related Diagnostic issues
Individuals from a variety of cultural backgrounds sometimes exhibit defensive behaviors
and inteφersonal 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 sometimes 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 personality disorder can
be distinguished from delusional disorder, schizophrenia, and a bipolar or depressive disorder with psychotic features because these disorders are all characterized by a period of
persistent psychotic symptoms (e.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 and must persist when the psychotic symptoms
are in remission. When an individual has a persistent psychotic disorder (e.g., schizophrenia) that was preceded by schizoid personality disorder, schizoid personality disorder
should also be recorded, followed by "premorbid" in parentheses.
Autism spectrum disorder. There may be great difficulty differentiating individuals with
schizoid personality disorder from those with milder forms of autism spectrum disorder,
which may be differentiated by more severely impaired social interaction and stereotyped
behaviors and interests.
Personality change due to another medical condition. Schizoid personality disorder
must be distinguished from personality change due to another medical condition, in
which the traits that emerge are attributable to the effects of another medical condition on
the central nervous system.
Substance use disorders. Schizoid personality disorder must also be distinguished
from symptoms that may develop in association with persistent substance use.
Other personality disorders and personality traits. Other personality disorders may be
confused with schizoid personality disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differences
in their characteristic features. However, if an individual has personality features that
meet criteria for one or more personality disorders in addition to schizoid personality disorder, all can be diagnosed. Although characteristics of social isolation and restricted affectivity are common to schizoid, schizotypal, and paranoid personality disorders,
schizoid personality disorder can be distinguished from schizotypal personality disorder
by the lack of cognitive and perceptual distortions and from paranoid personality disorder
by the lack of suspiciousness and paranoid ideation. The social isolation of schizoid personality disorder can be distinguished from that of avoidant personality disorder, which is
attributable to fear of being embarrassed or found inadequate and excessive anticipation
of rejection. In contrast, people with schizoid personality disorder have a more pervasive
detachment and limited desire for social intimacy. Individuals with obsessive-compulsive
personality disorder may also show an apparent social detachment stemming from devotion to work and discomfort with emotions, but they do have an underlying capacity for
intimacy.
Individuals who are "loners" may display personality traits that might be considered
schizoid. Only when these traits are inflexible and maladaptive and cause significant functional impairment or subjective distress do they constitute schizoid personality disorder.
Schizotypal Personality Disorder
Diagnostic Criteria 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.
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 associated with paranoid fears rather than negative judgments about self.
B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or
depressive disorder with psychotic features, another psychotic disorder, or autism
spectrum disorder.
Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,” e.g., “schizotypal personality disorder (premorbid).”
Diagnostic Features
The essential feature of schizotypal personality disorder is a pervasive pattern of social
and interpersonal deficits marked by acute discomfort with, and reduced capacity for,
close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior. This pattern begins by early adulthood and is present in a variety of contexts.
Individuals with schizotypal personality disorder often have ideas of reference (i.e., incorrect interpretations of casual incidents and external events as having a particular and
unusual meaning specifically for the person) (Criterion Al). These should be distinguished from delusions of reference, in which the beliefs are held with delusional conviction. These individuals may be superstitious or preoccupied with paranormal phenomena
that are outside the norms of their subculture (Criterion A2). They may feel that they have
special powers to sense events before they happen or to read others' thoughts. They may
believe that they have magical control over others, which can be implemented directly
(e.g., believing that their spouse's taking the dog out for a walk is the direct result of thinking an hour earlier it should be done) or indirectly through compliance with magical rituals (e.g., walking past a specific object three times to avoid a certain harmful outcome).
Perceptual alterations may be present (e.g., sensing that another person is present or hearing a voice murmuring his or her name) (Criterion A3). Their speech may include unusual
or idiosyncratic phrasing and construction. It is often loose, digressive, or vague, but without actual derailment or incoherence (Criterion A4). Responses can be either overly concrete or overly abstract, and words or concepts are sometimes applied in unusual ways
(e.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 are intent on undermining their reputation with
the boss) (Criterion A5). They are usually not able to negotiate the full range of affects and
interpersonal cuing required for successful relationships and thus often appear to interact
with others in an inappropriate, stiff, or constricted fashion (Criterion A6). These individuals are often considered to be odd or eccentric because of unusual mannerisms, an often
unkempt manner of dress that does not quite "fit together," and inattention to the usual
social conventions (e.g., the individual may avoid eye contact, wear clothes that are ink
stained and ill-fitting, and be unable to join in the give-and-take banter of co-workers)
(Criterion A7).
Individuals with schizotypal personality disorder experience interpersonal relatedness as problematic and are uncomfortable relating to other people. Although they may
express unhappiness about their lack of relationships, their behavior suggests a decreased
desire for intimate contacts. As a result, they usually have no or few close friends or confidants other than a first-degree relative (Criterion A8). They are anxious in social situations, particularly those involving unfamiliar people (Criterion A9). They will interact
with other individuals when they have to but prefer to keep to themselves because they
feel that they are different and just do not "fit in." Their social anxiety does not easily abate.
even when they spend more time in the setting or become more familiar with the other
people, because t^heir anxiety tends to be associated with suspiciousness regarding others'
motivations. For example, when attending a dinner party, the individual with schizotypal
personality disorder will not become more relaxed as time goes on, but rather may become
increasingly tense and suspicious.
Schizotypal personality disorder should not be diagnosed if the pattern of behavior occurs exclusively during the course of schizophrenia, a bipolar or depressive disorder with
psychotic features, another psychotic disorder, or autism spectrum disorder (Criterion B).
Associated Features Supporting Diagnosis
Individuals with schizotypal personality disorder 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, individuals with this disorder may experience transient
psychotic episodes (lasting minutes to hours), although they usually are insufficient in duration to warrant an additional diagnosis such as brief psychotic disorder or schizophreniform disorder. In some cases, clinically significant psychotic symptoms may develop that
meet criteria for brief psychotic disorder, schizophreniform disorder, delusional disorder,
or schizophrenia. Over half may have a history of at least one major 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 cooccurrence with schizoid, paranoid, avoidant, 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. community 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 Epidemiologic Survey on Alcohol and Related Conditions.
Development and Course
Schizotypal personality disorder has a relatively stable course, with only a small proportion of individuals going on to develop schizophrenia or another psychotic disorder.
Schizotypal personality disorder may be first apparent in childhood and adolescence with
solitariness, poor peer relationships, social anxiety, underachievement in school, hypersensitivity, peculiar thoughts and language, and bizarre fantasies. These children may appear "odd" or "eccentric" and attract teasing.
Risk and Prognostic Factors
Genetic and physiological. Schizotypal personality disorder appears to aggregate familially and is more prevalent among the first-degree biological relatives of individuals
with schizophrenia than among the general population. There may also be a modest increase 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 culturally determined characteristics, particularly those regarding religious beliefs and rituals, can appear to be schizotypal to the uninformed outsider
(e.g., voodoo, speaking in tongues, life beyond death, shamanism, mind reading, sixth
sense, evil eye, magical beliefs related to health and illness).
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 delusional disorder, schizophrenia, and a bipolar or depressive
disorder with psychotic features because these disorders are all characterized by a period
of persistent psychotic symptoms (e.g., delusions and hallucinations). To give an additional diagnosis of schizotypal personality disorder, the personality disorder must have
been present before the onset of psychotic symptoms and persist when the psychotic
symptoms are in remission. When an individual has a persistent psychotic disorder (e.g.,
schizophrenia) that was preceded by schizotypal personality disorder, schizotypal personality disorder should also be recorded, followed by "premorbid" in parentheses.
Neurodevelopmental disorders. There may be great difficulty differentiating children
with schizotypal personality disorder from the heterogeneous group of solitary, odd children whose behavior is characterized by marked social isolation, eccentricity, or peculiarities of language and whose diagnoses would probably include milder forms of autism
spectrum disorder or language communication disorders. Communication disorders may
be differentiated by the primacy and severity of the disorder in language and by the characteristic features of impaired language found in a specialized language assessment.
Milder forms of autism spectrum disorder are differentiated by the even greater lack of social awareness and emotional reciprocity and stereotyped behaviors and interests.
Personality change due to another medical condition. Schizotypal personality disorder must be distinguished from personality change due to another medical condition, in
which the traits that emerge are attributable to the effects of another medical condition on
the central nervous system.
Substance use disorders. Schizotypal personality disorder must also be distinguished
from symptoms that may develop in association with persistent substance use.
Other personality disorders and personality traits. Other personality disorders may
be confused with schizotypal personality disorder because they have certain features in
common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features
that meet criteria for one or more personality disorders in addition to schizotypal personality disorder, all can be diagnosed. Although paranoid and schizoid personality disorders may also be characterized by social detachment and restricted affect, schizotypal
personality disorder can be distinguished from these two diagnoses by the presence of
cognitive or perceptual distortions and marked eccentricity or oddness. Close relationships are limited in both schizotypal personality disorder and avoidant personality disorder; however, in avoidant personality disorder an active desire for relationships is
constrained by a fear of rejection, whereas in schizotypal personality disorder there is
a lack of desire for relationships and persistent detachment. Individuals with narcissistic
personality disorder may also display suspiciousness, social withdrawal, or alienation,
but in narcissistic personality disorder these qualities derive primarily from fears of having imperfections or flaws revealed. Individuals with borderline personality disorder may
also have transient, psychotic-like symptoms, but these are usually more closely related to
affective shifts in response to stress (e.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 symptoms that may worsen under stress but are less likely to be invariably associated with pronounced affective symptoms. Although social isolation may occur in borderline personality
disorder, it is usually secondary to repeated interpersonal failures due to angry outbursts
and frequent mood shifts, rather than a result of a persistent lack of social contacts and desire for intimacy. Furthermore, individuals with schizotypal personality disorder do not
usually demonstrate the impulsive or manipulative behaviors of the individual with borderline personality disorder. However, there is a high rate of co-occurrence between the
two disorders, so that making such distinctions is not always feasible. Schizotypal features
during adolescence may be reflective of transient emotional turmoil, rather than an enduring personality disorder.
Cluster B Personality Disorders
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.
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 schizophrenia 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 antisocial 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 repetitive and persistent pattern of behavior in
which the basic rights of others or major age-appropriate societal norms or rules are violated. The specific behaviors characteristic of conduct disorder fall into one of four categories: aggression to people and animals, destruction of property, deceitfulness or theft, or
serious violation of rules.
The pattern of antisocial behavior continues into adulthood. Individuals with antisocial personality disorder fail to conform to social norms with respect to lawful behavior
(Criterion Al). They may repeatedly perform acts that are grounds for arrest (whether
they are arrested or not), such as destroying property, harassing others, stealing, or pursuing illegal occupations. Persons with this disorder disregard the wishes, rights, or feelings of others. They are frequently deceitful and manipulative in order to gain personal
profit or pleasure (e.g., to obtain money, sex, or power) (Criterion A2). They may repeatedly lie, use an alias, con others, or malinger. A pattern of impulsivity 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 for the consequences to self or others; this
may lead to sudden changes of jobs, residences, or relationships. Individuals with antisocial personality disorder tend to be irritable and aggressive and may repeatedly get into
physical fights or commit acts of physical assault (including spouse beating or child beating) (Criterion A4). (Aggressive acts that are required to defend oneself or someone else
are not considered to be evidence for this item.) These individuals also display a reckless
disregard for the safety of themselves or others (Criterion A5). This may be evidenced in
their driving behavior (i.e., recurrent speeding, driving while intoxicated, multiple accidents). They may engage in sexual behavior or substance use that has a high risk for harmful consequences. They may neglect or fail to care for a child in a way that puts the child in
danger.
Individuals with antisocial personality disorder also tend to be consistently and extremely irresponsible (Criterion A6). Irresponsible work behavior may be indicated by significant periods of unemployment despite available job opportunities, or by abandonment
of several jobs without a realistic plan for getting another job. There may also be a pattern
of repeated absences from 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, failing to provide child support, or failing to support other dependents on a regular basis. Individuals with antisocial personality disorder show little remorse for the consequences of
their acts (Criterion A7). They may be indifferent to, or provide a superficial rationalization for, having hurt, mistreated, or stolen from someone (e.g., 'Tife's unfair," "losers deserve 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 exclusively during the course of schizophrenia
or bipolar disorder (Criterion D).
Associated Features Supporting Diagnosis
Individuals with antisocial personality disorder frequently lack empathy and tend to be
callous, cynical, and contemptuous of the feelings, rights, and sufferings of others. They
may have an inflated and arrogant self-appraisal (e.g., feel that ordinary work is beneath
them or lack a realistic concern about their current problems or their future) and may be
excessively opinionated, self-assured, or cocky. 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 the topic). Lack of empathy, inflated selfappraisal, and superficial charm are features that have been commonly included in traditional conceptions of psychopathy that may be particularly distinguishing of the disorder
and more predictive of recidivism in prison or forensic settings, where criminal, delinquent, or aggressive acts are likely to be nonspecific. These individuals may also be irresponsible and exploitative in their sexual relationships. They may have a history of many
sexual partners and may never have sustained a monogamous relationship. They may be
irresponsible as parents, as evidenced by malnutrition of a child, an illness in the child resulting from a \aèk of minimal hygiene, a child'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 dishonorable discharges from the armed services, may fail to be self-supporting, may become impoverished or even homeless, or may
spend many years in penal institutions. Individuals with antisocial personality disorder
are more likely than people in the general population to die prematurely by violent means
(e.g., suicide, accidents, homicides).
Individuals with antisocial personality disorder may also experience dysphoria, including complaints of tension, inability to tolerate boredom, and depressed mood. They
may have associated anxiety disorders, depressive disorders, substance use disorders, somatic symptom disorder, gambling disorder, and other disorders of impulse control. Individuals with antisocial personality disorder also often have personality features that
meet criteria for other personality disorders, particularly borderline, histrionic, and narcissistic personality disorders. The likelihood of developing antisocial personality disorder in adult life is increased if the individual experienced childhood onset of conduct
disorder (before age 10 years) and accompanying attention-deficit/hyperactivity disorder.
Child abuse or neglect, unstable or erratic parenting, or inconsistent parental discipline
may increase the likelihood that conduct disorder will evolve into antisocial personality
disorder.
Prevalence
Twelve-month prevalence rates of antisocial personality disorder, using criteria from previous DSMs, are between 0.2% and 3.3%. The highest prevalence of antisocial personality
disorder (greater than 70%) is among most severe samples of males with alcohol use disorder and from substance abuse clinics, prisons, 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 decade of life. Although this remission 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 personality 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 increased 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 disorder and substance use disorders, whereas females more often have somatic symptom disorder. However, in such families, there is an
increase in prevalence of all of these disorders in both males and females compared with
the general population. Adoption studies indicate 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
risk of developing antisocial personality disorder, somatic symptom disorder, and substance use disorders. Adopted-away children resemble their biological parents more than
their adoptive parents, but the adoptive family environment influences the risk of developing 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 misapplied to individuals in settings in which seemingly antisocial behavior may be part of a
protective survival strategy. In assessing antisocial traits, it is helpful for the clinician to
consider the social and economic context 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 personality disorder may be underdiagnosed in females, particularly because of the emphasis on aggressive items in the definition of conduct 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 history of some symptoms of conduct disorder before age 15 years. For individuals older than 18 years, a diagnosis of conduct disorder is
given only if the criteria for antisocial personality disorder are not met.
Substance use disorders. When antisocial behavior in an adult is associated with a
substance use disorder, the diagnosis of antisocial personality disorder is not made unless
the signs of antisocial personality disorder were also present in childhood and have continued into adulthood. When substance use and antisocial behavior both began in childhood
and continued into adulthood, both a substance use disorder and antisocial personality
disorder should be diagnosed if the criteria for both are met, even though some antisocial
acts may be a consequence of the substance use disorder (e.g., illegal selling of drugs, thefts
to obtain money for drugs).
Schizophrenia and bipolar disorders. Antisocial behavior that occurs exclusively during the course of schizophrenia or a bipolar disorder should not be diagnosed as antisocial
personality disorder.
Other personality disorders. Other personality disorders may be confused with antisocial personality disorder because they have certain features in common. It is therefore important to distinguish among these disorders based on differences in their characteristic
features. However, if an individual has personality features that meet criteria for one or
more personality disorders in addition to antisocial personality disorder, all can be diagnosed. Individuals with antisocial personality disorder and narcissistic personality disorder share a tendency to be tough-minded, glib, superficial, exploitative, and lack empathy.
However, narcissistic personality disorder does not include characteristics of impulsivity,
aggression, and deceit. In addition, individuals with antisocial personality disorder may
not be as needy of the admiration and envy of others, and persons with narcissistic personality disorder usually lack the history of conduct disorder in childhood or criminal
behavior in adulthood. Individuals with antisocial personality disorder and histrionic
personality disorder share a tendency to be impulsive, superficial, excitement seeking,
reckless, seductive, and manipulative, but persons with histrionic personality disorder
tend to be more exaggerated in their emotions and do not characteristically engage in antisocial behaviors. Individuals with histrionic and borderline personality disorders are
manipulative to gain nurturance, whereas those with antisocial personality disorder are
manipulative to gain profit, power, or some other material gratification. Individuals with
antisocial personality disorder tend to be less emotionally unstable and more aggressive
than those with borderline personality disorder. Although antisocial behavior may be
present in some individuals with paranoid personality disorder, it is not usually motivated by a desire for personal gain or to exploit others as in antisocial personality disorder,
but rather is more often attributable to a desire for revenge.
Criminal behavior not associated with a personality disorder. Antisocial personality
disorder must be distinguished from criminal behavior undertaken for gain that is not accompanied by the personality features characteristic of this disorder. Only when antisocial
personality traits are inflexible, maladaptive, and persistent and cause significant functional impairment or subjective distress do they constitute antisocial personality disorder.
Borderline Personality Disorder
Diagnostic Criteria 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 alternating 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 selfmutilating 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, and affects, and marked impulsivity that begins
by early adulthood and is present in a variety of contexts.
Individuals with borderline personality disorder make frantic efforts to avoid real or
imagined abandonment (Criterion 1). The perception of impending separation or rejection,
or the loss of external structure, can lead to profound changes in self-image, affect, cognition,
and behavior. These individuals are very sensitive to environmental circumstances. They experience intense abandonment fears and inappropriate anger even when faced with a realistic time-limited separation or when there are unavoidable changes in plans (e.g., sudden
despair in reaction to a clinician's announcing the end of the hour; panic or fury when someone important to them is just a few minutes late or must cancel an appointment). They may
believe that this "abandonment" implies they are "bad." These abandonment fears are related to an intolerance of being alone and a need to have other people with them. Their frantic
efforts to avoid abandonment may include impulsive actions such as self-mutilating or suicidal behaviors, which are described separately in Criterion 5.
Individuals with borderline personality disorder have a pattern of unstable and intense
relationships (Criterion 2). They may idealize potential caregivers or lovers at the first or
second meeting, demand to spend a lot of time together, and share the most intimate details
early in a relationship. However, they may switch quickly from idealizing other people to
devaluing them, feeling that the other person does not care enough, does not give enough,
or is not "there" enough. These individuals can empathize with and nurture other people,
but only with the expectation that the other person will "be there" in return to meet their
own needs on demand. These individuals are prone to sudden and dramatic shifts in their
view of others, who may alternatively be seen as beneficent supports or as cruelly punitive.
Such shifts often reflect disillusionment with a caregiver whose nurturing qualities had
been idealized or whose rejection or abandonment is expected.
There may be an identity disturbance characterized by markedly and persistently unstable self-image or sense of self (Criterion 3). There are sudden and dramatic shifts in selfimage, characterized by shifting goals, values, and vocational aspirations. There may be
sudden changes in opinions and plans about career, sexual identity, values, and types of
friends. These individuals may suddenly change from the role of a needy supplicant for
help to that of a righteous avenger of past mistreatment. Although they usually have a selfimage that is based on being bad or evil, individuals with this disorder may at times have
feelings that they do not exist at all. Such experiences usually occur in situations in which
the individual feels a lack of a meaningful relationship, nurturing, and support. These individuals may show worse performance in unstructured work or school situations.
Individuals with borderline personality disorder display impulsivity in at least two areas
that are potentially self-damaging (Criterion 4). They may gamble, spend money irresponsibly, binge eat, abuse substances, engage in unsafe sex, or drive recklessly. Individuals
with this disorder display recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior (Criterion 5). Completed suicide occurs in 8%-10% of such individuals, and
self-mutilative acts (e.g., cutting or burning) and suicide threats and attempts are very
common. Recurrent suicidality is often the reason that these individuals present for help.
These self-destructive acts are usually precipitated by threats of separation or rejection or
by expectations that the individual assumes increased responsibility. Self-mutilation may
occur during dissociative experiences and often brings relief by reaffirming the ability to
feel or by expiating the individual's sense of being evil.
Individuals with borderline personality disorder may display affective instability that
is due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days) (Criterion 6). The
basic dysphoric mood of those with borderline personality disorder is often disrupted by
periods of anger, panic, or despair and is rarely relieved by periods of well-being or satisfaction. These episodes may reflect the individual's extreme reactivity to interpersonal
stresses. Individuals with borderline personality disorder may be troubled by chronic feelings of emptiness (Criterion 7). Easily bored, they may constantly seek something to do.
Individuals with this disorder frequently express inappropriate, intense anger or have difficulty controlling their anger (Criterion 8). They may display extreme sarcasm, enduring
bitterness, or verbal outbursts. The anger is often elicited when a caregiver or lover is seen
as neglectful, withholding, uncaring, or abandoning. Such expressions of anger are often
followed by shame and guilt and contribute to the feeling they have of being evil. During
periods of extreme stress, transient paranoid ideation or dissociative symptoms (e.g., depersonalization) may occur (Criterion 9), but these are generally of insufficient severity or
duration to warrant an additional diagnosis. These episodes occur most frequently in response to a real or imagined abandonment. Symptoms tend to be transient, lasting minutes or hours. The real or perceived return of the caregiver's nurturance may result in a
remission of symptoms.
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 severely after a discussion of how well therapy is going; destroying a good relationship just when it is clear that the relationship could last). Some individuals develop psychotic-like symptoms (e.g., hallucinations, body-image distortions,
ideas of reference, hypnagogic phenomena) during times of stress. Individuals with this
disorder may feel more secure with transitional objects (i.e., a pet or inanimate possession)
than in interpersonal relationships. Premature death from suicide may occur in individuals with this disorder, especially in those with co-occurring depressive disorders or substance use disorders. Physical handicaps may result from self-inflicted abuse behaviors or
failed suicide attempts. Recurrent job losses, interrupted education, and separation or divorce are common. Physical and sexual abuse, neglect, hostile conflict, and early parental
loss are more common in the childhood histories of those with borderline personality disorder. Common co-occurring disorders include depressive and bipolar disorders, substance use disorders, eating disorders (notably bulimia nervosa), posttraumatic stress
disorder, and attention-deficit/hyperactivity disorder. Borderline personahty disorder
also frequently co-occurs with the other personality disorders.
Prevalence
The median population prevalence of borderline personality disorder is estimated to be
1.6% but may be as high as 5.9%. The prevalence of borderline personality disorder is
about 6% in primary care settings, about 10% among individuals seen in outpatient mental
health clinics, and about 20% among psychiatric 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 personahty disorder. The most
common pattern is one of chronic instability in early adulthood, with episodes of serious
affective and impulsive dyscontrol and high levels of use of health and mental health resources. 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 toward intense emotions, impulsivity, and intensity in relationships is often lifelong, individuals who engage in therapeutic intervention 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. Follow-up studies of individuals identified through outpatient mental health clinics indicate
that after about 10 years, as many as half of the individuals no longer have a pattern of behavior 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 general population. There is also an increased familial risk for substance use disorders, antisocial 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 young adults with identity problems (especially
when accompanied by substance use) may transiently display behaviors that misleadingly
give the impression of borderline personality disorder. Such situations are characterized by
emotional instability, "existential" dilemmas, uncertainty, anxiety-provoking choices, conflicts about sexual orientation, and competing social pressures to decide on careers.
Gender-Related Diagnostic issues
Borderline personality disorder 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 borderline personality disorder can be mimicked
by an episode of depressive or bipolar disorder, the clinician should avoid giving an additional diagnosis of borderline personality disorder based only on cross-sectional presentation without having documented that the pattern of behavior had an early onset and a longstanding course.
Other personality disorders. Other personality disorders may be confused with borderline personality disorder because they have certain features in common. It is therefore important to distinguish among these disorders based on differences in their characteristic
features. However, if an individual has personality features that meet criteria for one or
more personality disorders in addition to borderline personality disorder, all can be diagnosed. Although histrionic personality disorder can also be characterized by attention seeking, manipulative behavior, and rapidly shifting emotions, borderline personality disorder
is distinguished by self-destructiveness, angry disruptions in close relationships, and
chronic feelings of deep emptiness and loneliness. Paranoid ideas or illusions may be present in both borderline personality disorder and schizotypal personality disorder, but these
symptoms are more transient, interpersonally reactive, and responsive to external structuring in borderline personality disorder. Although paranoid personality disorder and narcissistic personality disorder may also be characterized by an angry reaction to minor stimuli,
the relative stability of self-image, as well as the relative lack of self-destructiveness, impulsivity, and abandonment concerns, distinguishes these disorders from borderline personality disorder. Although antisocial personality disorder and borderline personality disorder
are both characterized by manipulative behavior, individuals with antisocial personality
disorder are manipulative to gain profit, power, or some other material gratification,
whereas the goal in borderline personality disorder is directed more toward gaining the concern of caretakers. Both dependent personality disorder and borderline personality disorder
are characterized by fear of abandonment; however, the individual with borderline personality disorder reacts to abandonment with feelings of emotional emptiness, rage, and demands, whereas the individual with dependent personality disorder reacts with increasing
appeasement and submissiveness and urgently seeks a replacement relationship to provide
caregiving and support. Borderline personality disorder can further be distinguished from
dependent personality disorder by the typical pattern of unstable and intense relationships.
Personality change due to another medical condition. Borderline personality disorder must be distinguished from personality change due to another medical condition, in
which the traits that emerge are attributable to the effects of another medical condition on
the central nervous system.
Substance use disorders. Borderline personality disorder must also be distinguished
from symptoms that may develop in association with persistent substance use.
Identity problems. Borderline personality disorder should be distinguished from an
identity problem, which is reserved for identity concerns related to a developmental phase
(e.g., adolescence) and does not qualify as a mental disorder.
Histrionic Personality Disorder
Diagnostic Criteria 301.50 (F60.4)
A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Is uncomfortable in situations in which he or she is not the center of attention.
2. Interaction with others is often characterized by inappropriate sexually seductive or
provocative behavior.
3. Displays rapidly shifting and shallow expression of emotions.
4. Consistently uses physical appearance to draw attention to self.
5. Has a style of speech that is excessively impressionistic and lacking in detail.
6. Shows self-dramatization, theatricality, and exaggerated expression of emotion.
7. Is suggestible (i.e., easily influenced by others or circumstances).
8. Considers relationships to be more intimate than they actually are.
Diagnostic Features
The essential feature of histrionic personality disorder is pervasive and excessive emotionality and attention-seeking behavior. This pattern begins by early adulthood and is present in a variety of contexts.
Individuals with histrionic personality disorder are uncomfortable or feel unappreciated when they are not the center of attention (Criterion 1). Often lively and dramatic, they
tend to draw attention to themselves and may initially charm new acquaintances by their
enthusiasm, apparent openness, or flirtatiousness. These qualities wear thin, however, as
these individuals continually demand to be the center of attention. They commandeer the
role of "the life of the party." If they are not the center of attention, they may do something
dramatic (e.g., make up stories, create a scene) to draw the focus of attention to themselves.
This need is often apparent in their behavior with a clinician (e.g., being flattering, bringing gifts, providing dramatic descriptions of physical and psychological symptoms that
are replaced by new symptoms each visit).
The appearance and behavior of individuals with this disorder are often inappropriately sexually provocative or seductive (Criterion 2). This behavior not only is directed toward persons in whom the individual has a sexual or romantic interest but also occurs in
a wide variety of social, occupational, and professional relationships beyond what is appropriate for the social context. Emotional expression may be shallow and rapidly shifting
(Criterion 3). Individuals with this disorder consistently use physical appearance to draw
attention to themselves (Criterion 4). They are overly concerned with impressing others by
their appearance and expend an excessive amount of time, energy, and money on clothes
and grooming. They may "fish for compliments" regarding appearance and may be easily
and excessively upset by a critical conunent about how they look or by a photograph that
they regard as unflattering.
These individuals have a style of speech that is excessively impressionistic and lacking
in detail (Criterion 5). Strong opinions are expressed with dramatic flair, but underlying
reasons are usually vague and diffuse, without supporting facts and details. For example,
an individual with histrionic personality disorder may comment that a certain individual
is a wonderful human being, yet be unable to provide any specific examples of good qualities to support this opinion. Individuals with this disorder are characterized by selfdramatization, theatricality, and an exaggerated expression of emotion (Criterion 6). They
may embarrass friends and acquaintances by an excessive public display of emotions (e.g.,
embracing casual acquaintances with excessive ardor, sobbing uncontrollably on minor
sentimental occasions, having temper tantrums). However, their emotions often seem to
be turned on and off too quickly to be deeply felt, which may lead others to accuse the individual of faking these feelings.
Individuals with histrionic personality disorder have a high degree of suggestibility (Criterion 7). Their opinions and feelings are easily influenced by others and by current fads.
They may be overly trusting, especially of strong authority figures whom they see as magically solving their problems. They have a tendency to play hunches and to adopt convictions quickly. Individuals with this disorder often consider relationships more intimate
than they actually are, describing almost every acquaintance as "my dear, dear friend" or
referring to physicians met only once or twice under professional circumstances by their
first names (Criterion 8).
Associated Features Supporting Diagnosis
Individuals with histrionic personality disorder may have difficulty achieving emotional intimacy in romantic or sexual relationships. Without being aware of it, they often act out a
role (e.g., "victim" or "princess") in their relationships to others. They may seek to control
their partner through emotional manipulation or seductiveness on one level, while displaying a marked dependency on them at another level. Individuals with this disorder often
have impaired relationships with same-sex friends because their sexually provocative interpersonal style may seem a threat to their friends' relationships. These individuals may also
alienate friends with demands for constant attention. They often become depressed and upset when they are not the center of attention. They may crave novelty, stimulation, and excitement and have a tendency to become bored with their usual routine. These individuals
are often intolerant of, or frustrated by, situations that involve delayed gratification, and
their actions are often directed at obtaining immediate satisfaction. Although they often initiate a job or project with great enthusiasm, their interest may lag quickly. Longer-term relationships may be neglected to make way for the excitement of new relationships.
The actual risk of suicide is not known, but clinical experience suggests that individuals with this disorder are at increased risk for suicidal gestures and threats to get attention
and coerce better caregiving. Histrionic personality disorder has been associated with
higher rates of somatic symptom disorder, conversion disorder (functional neurological
symptom disorder), and major depressive disorder. Borderline, narcissistic, antisocial, and
dependent personality disorders often co-occur.
Prevalence
Data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions suggest a prevalence of histrionic personality of 1.84%.
Culture-Related Diagnostic Issues
Norms for interpersonal behavior, personal appearance, and emotional expressiveness
vary widely across cultures, genders, and age groups. Before considering the various traits
(e.g., emotionality, seductiveness, dramatic interpersonal style, novelty seeking, sociability, charm, impressionability, a tendency to somatization) to be evidence of histrionic personality disorder, it is important to evaluate whether they cause clinically significant
impairment or distress.
Gender-Related Diagnostic Issues
In clinical settings, this disorder has been diagnosed more frequently in females; however,
the sex ratio is not significantly different from the sex ratio of females within the respective
clinical setting. In contrast, some studies using structured assessments report similar prevalence rates among males and females.
Differential Diagnosis
Other personality disorders and personality traits. Other personality disorders may
be confused with histrionic personality disorder because they have certain features in
common. It is therefore important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features
that meet criteria for one or more personality disorders in addition to histrionic personality disorder, all can be diagnosed. Although borderline personality disorder can also be
characterized by attention seeking, manipulative behavior, and rapidly shifting emotions,
it is distinguished by self-destructiveness, angry disruptions in close relationships, and
chronic feelings of deep emptiness and identity disturbance. Individuals with antisocial
personality disorder and histrionic personality disorder share a tendency to be impulsive,
superficial, excitement seeking, reckless, seductive, and manipulative, but persons with
histrionic personality disorder tend to be more exaggerated in their emotions and do not
characteristically engage in antisocial behaviors. Individuals with histrionic personality
disorder are manipulative to gain nurturance, whereas those with antisocial personality
disorder are manipulative to gain profit, power, or some other material gratification. Although individuals with narcissistic personality disorder also crave attention from others,
they usually want praise for their '"superiority," whereas individuals with histrionic personality disorder are willing to be viewed as fragile or dependent if this is instrumental in
getting attention. Individuals with narcissistic personality disorder may exaggerate the
intimacy of their relationships with other people, but they are more apt to emphasize the
"VIP" status or wealth of their friends. In dependent personality disorder, the individual
is excessively dependent on others for praise and guidance, but is without the flamboyant,
exaggerated, emotional features of individuals with histrionic personality disorder.
Many individuals may display histrionic personality traits. Only when these traits are
inflexible, maladaptive, and persisting and cause significant functional impairment or
subjective distress do they constitute histrionic personality disorder.
Personality change due to another medical condition. Histrionic personality disorder
must be distinguished from personality change due to another medical condition, in
which the traits that emerge are attributable to the effects of another medical condition on
the central nervous system.
Substance use disorders. The disorder must also be distinguished from sjonptoms that
may develop in association with persistent substance use.
Narcissistic Personality Disorder
Diagnostic Criteria 301.81 (F60.81)
A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack
of empathy, beginning by early adulthood and present in a variety of contexts, as indicated
by five (or more) of the following:
1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents,
expects to be recognized as superior without commensurate achievements).
2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal
love.
3. Believes that he or she is “special” and unique and can only be understood by, or
should associate with, other special or high-status people (or institutions).
4. Requires excessive admiration.
5. Has a sense of entitlement (i.e., unreasonable expectations of especially favorable
treatment or automatic compliance with his or her expectations).
6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own
ends).
7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
8. Is often envious of others or believes that others are envious of him or her.
9. Shows arrogant, haughty behaviors or attitudes.
Diagnostic Features
The essential feature of narcissistic personality disorder is a pervasive pattern of grandiosity, need for admiration, and lack of empathy that begins by early adulthood and is present in a variety of contexts.
Individuals with this disorder have a grandiose sense of self-importance (Criterion 1).
They routinely overestimate their abilities and inflate their accomplishments, often appearing
boastful and pretentious. They may blithely assume that others attribute the same value to
their efforts and may be surprised when the praise they expect and feel they deserve is not
forthcoming. Often implicit in the inflated judgments of their own accomplishments is an underestimation (devaluation) of the contributions of others. Individuals with narcissistic personality disorder are often preoccupied with fantasies of unlimited success, power, brilliance,
beauty, or ideal love (Criterion 2). They may ruminate about "'long overdue" admiration and
privilege and compare themselves favorably with famous or privileged people.
Individuals with narcissistic personality disorder believe that they are superior, special, or unique and expect others to recognize them as such (Criterion 3). They may feel
that they can only be understood by, and should only associate with, other people who are
special or of high status and may attribute "unique," "perfect," or "gifted" qualities to those
with whom they associate. Individuals with this disorder believe that their needs are special and beyond the ken of ordinary people. Their own self-esteem is enhanced (i.e., "mirrored") by the idealized value that they assign to those with whom they associate. They are
likely to insist on having only the "top" person (doctor, lawyer, hairdresser, instructor) or
being affiliated with the "best" institutions but may devalue the credentials of those who disappoint them.
Individuals with this disorder generally require excessive admiration (Criterion 4). Their
self-esteem is almost invariably very fragile. Tliey may be preoccupied with how well they
are doing and how favorably they are regarded by others. This often takes the form of a need
for constant attention and admiration. They may expect their arrival to be greeted with great
farifare and are astonished if others do not covet their possessions. They may constantly fish
for compliments, often with great charm. A sense of entitlement is evident in these individuals' unreasonable expectation of especially favorable treatment (Criterion 5). They expect
to be catered to and are puzzled or furious when this does not happen. For example, they
may assume that they do not have to wait in line and that their priorities are so important
that others should defer to them, and then get irritated when others fail to assist "in their
very important work." This sense of entitlement, combined with a lack of sensitivity to the
wants and needs of others, may result in the conscious or unwitting exploitation of others
(Criterion 6). They expect to be given whatever they want or feel they need, no matter what
it might mean to others. For example, these individuals may expect great dedication from
others and may overwork them without regard for the impact on their lives. They tend to
form friendships or romantic relationships only if the other person seems likely to advance
their purposes or otherwise enhance their self-esteem. They often usuφ special privileges
and extra resources that they believe they deserve because they are so special.
Individuals with narcissistic personality disorder generally have a lack of empathy and
have difficulty recognizing the desires, subjective experiences, and feelings of others (Criterion 7). They may assume that others are totally concerned about their welfare. They tend to
discuss their own concerns in inappropriate and lengthy detail, while failing to recognize
that others also have feelings and needs. They are often contemptuous and impatient with
others who talk about their own problems and concerns. These individuals may be oblivious
to the hurt their remarks may inflict (e.g., exuberantly telling a former lover that "I am now
in the relationship of a lifetime!"; boasting of health in front of someone who is sick). When
recognized, the needs, desires, or feelings of others are likely to be viewed disparagingly as
signs of weakness or vulnerability. Those who relate to individuals with narcissistic personality disorder typically find an emotional coldness and lack of reciprocal interest.
These individuals are often envious of others or believe that oéiers are envious of them
(Criterion 8). They may begrudge others their successes or possessions, feeling that they better
deserve those achievements, admiration, or privileges. They may harshly devalue the contributions of others, particularly when those individuals have received acknowledgment or
praise for their accomplishments. Arrogant, haughty behaviors characterize these individuals;
they often display snobbish, disdainful, or patronizing attitudes (Criterion 9). For example, an
individual with this disorder may complain about a clumsy waiter's "rudeness" or "stupidity"
or conclude a medical evaluation with a condescending evaluation of the physician.
Associated Features Supporting Diagnosis
Vulnerability in self-esteem makes individuals with narcissistic personality disorder very
sensitive to "injury" from criticism or defeat. Although they may not show it outwardly,
criticism may haunt these individuals and may leave them feeling humiliated, degraded,
hollow, and empty. They may react with disdain, rage, or defiant counterattack. Such experiences often lead to social withdrawal or an appearance of humility that may mask and
protect the grandiosity. Interpersonal relations are typically impaired because of problems
derived from entitlement, the need for admiration, and the relative disregard for the sensitivities of others. Though overweening ambition and confidence may lead to high
achievement, performance may be disrupted because of intolerance of criticism or defeat.
Sometimes vocational functioning can be very low, reflecting an unwillingness to take a
risk in competitive or other situations in which defeat is possible. Sustained feelings of
shame or humiliation and the attendant self-criticism may be associated with social withdrawal, depressed mood, and persistent depressive disorder (dysthymia) or major depressive disorder. In contrast, sustained periods of grandiosity may be associated with a
hypomanie mood. Narcissistic personality disorder is also associated with anorexia nervosa and substance use disorders (especially related to cocaine). Histrionic, borderline,
antisocial, and paranoid personality disorders may be associated with narcissistic personality disorder.
Prevalence
Prevalence estimates for narcissistic personality disorder, based on DSM-IV definitions,
range from 0% to 6.2% in community samples.
Development and Course
Narcissistic traits may be particularly common in adolescents and do not necessarily indicate that the individual will go on to have narcissistic personality disorder. Individuals
with narcissistic personality disorder may have special difficulties adjusting to the onset of
physical and occupational limitations that are inherent in the aging process.
Gender-Related Diagnostic Issues
Of those diagnosed with narcissistic personality disorder, 50%-75% are male.
Differential Diagnosis
Other personality disorders and personality traits. Other personality disorders may
be confused with narcissistic personality disorder because they have certain features in
common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features
that meet criteria for one or more personality disorders in addition to narcissistic personality disorder, all can be diagnosed. The most useful feature in discriminating narcissistic
personality disorder from histrionic, antisocial, and borderline personality disorders, in
which the interactive styles are coquettish, callous, and needy, respectively, is the grandiosity characteristic of narcissistic personality disorder. The relative stability of self-image
as well as the relative lack of self-destructiveness, impulsivity, and abandonment concerns
also help distinguish narcissistic personality disorder from borderline personality disorder. Excessive pride in achievements, a relative lack of emotional display, and disdain for
others' sensitivities help distinguish narcissistic personality disorder from histrionic
personality disorder. Although individuals with borderline, histrionic, and narcissistic
personality disorders may require much attention, those with narcissistic personality disorder specifically need that attention to be admiring. Individuals with antisocial and narcissistic personality disorders share a tendency to be tough-minded, glib, superficial,
exploitative, and unempathic. However, narcissistic personality disorder does not necessarily include characteristics of impulsivity, aggression, and deceit. In addition, individuals with antisocial personality disorder may not be as needy of the admiration and envy of
others, and persons with narcissistic personality disorder usually lack the history of conduct disorder in childhood or criminal behavior in adulthood. In both narcissistic personality disorder and obsessive-compulsive personality disorder, the individual may profess
a commitment to perfectionism and believe that others cannot do things as well. In contrast to the accompanying self-criticism of those with obsessive-compulsive personality
disorder, individuals with narcissistic personality disorder are more likely to believe that
they have achieved perfection. Suspiciousness and social withdrawal usually distinguish
those with schizotypal or paranoid personality disorder from those with narcissistic personality disorder. When these qualities are present in individuals with narcissistic personality disorder, they derive primarily from fears of having imperfections or flaws revealed.
Many highly successful individuals display personality traits that might be considered
narcissistic. Only when these traits are inflexible, maladaptive, and persisting and cause
significant functional impairment or subjective distress do they constitute narcissistic personality disorder.
Mania or hypomania. Grandiosity may emerge as part of manic or hypomanie episodes,
but the association with mood change or functional impairments helps distinguish these
episodes from narcissistic personality disorder.
Substance use disorders. Narcissistic personality disorder must also be distinguished
from symptoms that may develop in association with persistent substance use.
Cluster C Personality Disorders
Avoidant Personality Disorder
Diagnostic Criteria 301.82 (F60.6)
A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
1. Avoids occupational activities that involve significant interpersonal contact because of
fears of criticism, disapproval, or rejection.
2. Is unwilling to get involved with people unless certain of being liked.
3. Shows restraint within intimate relationships because of the fear of being shamed or
ridiculed. '
4. Is preoccupied with being criticized or rejected in social situations.
5. Is inhibited in new interpersonal situations because of feelings of inadequacy.
6. Views self as socially inept, personally unappealing, or inferior to others.
7. Is unusually reluctant to take personal risks or to engage in any new activities because
they may prove embarrassing.
Diagnostic Features
The essential feature of avoidant personality disorder is a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation that begins by
early adulthood and is present in a variety of contexts.
Individuals with avoidant personality disorder avoid work activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection (Criterion 1). Offers of job promotions may be declined because the new responsibilities might
result in criticism from co-workers. These individuals avoid making new friends unless
they are certain they will be liked and accepted without criticism (Criterion 2). Until they
pass stringent tests proving the contrary, other people are assumed to be critical and disapproving. Individuals with this disorder will not join in group activities unless there are
repeated and generous offers of support and nurturance. Interpersonal intimacy is often
difficult for these individuals, although they are able to establish intimate relationships
when there is assurance of uncritical acceptance. They may act with restraint, have difficulty talking about themselves, and withhold intimate feelings for fear of being exposed,
ridiculed, or shamed (Criterion 3).
Because individuals with this disorder are preoccupied with being criticized or rejected in social situations, they may have a markedly low threshold for detecting such reactions (Criterion 4). If someone is even slightly disapproving or critical, they may feel
extremely hurt. They tend to be shy, quiet, inhibited, and "invisible" because of the fear
that any attention would be degrading or rejecting. They expect that no matter what they
say, others will see it as "wrong," and so they may say nothing at all. They react strongly
to subtle cues that are suggestive of mockery or derision. Despite their longing to be active
participants in social life, they fear placing their welfare in the hands of others. Individuals
with avoidant personality disorder are inhibited in new interpersonal situations because
they feel inadequate and have low self-esteem (Criterion 5). Doubts concerning social
competence and personal appeal become especially manifest in settings involving interactions with strangers. These individuals believe themselves to be socially inept, personally unappealing, or inferior to others (Criterion 6). They are unusually reluctant to take
personal risks or to engage in any new activities because these may prove embarrassing
(Criterion 7). They are prone to exaggerate the potential dangers of ordinary situations,
and a restricted lifestyle may result from their need for certainty and security. Someone
with this disorder may cancel a job interview for fear of being embarrassed by not dressing
appropriately. Marginal somatic symptoms or other problems may become the reason for
avoiding new activities.
Associated Features Supporting Diagnosis
Individuals with avoidant personality disorder often vigilantly appraise the movements
and expressions of those with whom they come into contact. Their fearful and tense demeanor may elicit ridicule and derision from others, which in turn confirms their selfdoubts. These individuals are very anxious about the possibility that they will react to criticism with blushing or crying. They are described by others as being "shy," "timid,"
"lonely," and "isolated." The major problems associated with this disorder occur in social
and occupational functioning. The low self-esteem and hypersensitivity to rejection are
associated with restricted interpersonal contacts. These individuals may become relatively
isolated and usually do not have a large social support network that can help them weather
crises. They desire affection and acceptance and may fantasize about idealized relationships with others. The avoidant behaviors can also adversely affect occupational functioning because these individuals try to avoid the types of social situations that may be
important for meeting the basic demands of the job or for advancement.
Other disorders that are commonly diagnosed with avoidant personality disorder include depressive, bipolar, and anxiety disorders, especially social anxiety disorder (social
phobia). Avoidant personality disorder is often diagnosed with dependent personality
disorder, because individuals with avoidant personality disorder become very attached to
and dependent on those few other people with whom they are friends. Avoidant personality disorder also tends to be diagnosed with borderline personality disorder and with
the Cluster A personality disorders (i.e., paranoid, schizoid, or schizotypal personality
disorders).
Prevalence
Data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions suggest a prevalence of about 2.4% for avoidant personality disorder.
Development and Course
The avoidant behavior often starts in infancy or childhood with shyness, isolation, and
fear of strangers and new situations. Although shyness in childhood is a common precursor of avoidant personality disorder, in most individuals it tends to gradually dissipate as
they get older. In contrast, individuals who go on to develop avoidant personality disorder may become increasingly shy and avoidant during adolescence and early adulthood,
when social relationships with new people become especially important. There is some
evidence that in adults, avoidant personality disorder tends to become less evident or to
remit with age. This diagnosis should be used with great caution in children and adolescents, for whom shy and avoidant behavior may be developmentally appropriate.
Culture-Related Diagnostic issues
There may be variation in the degree to which different cultural and ethnic groups regard
diffidence and avoidance as appropriate. Moreover, avoidant behavior may be the result
of problems in acculturation following immigration.
Gender-Related Diagnostic Issues
Avoidant personality disorder appears to be equally frequent in males and females.
Differential Diagnosis
Anxiety disorders. There appears to be a great deal of overlap between avoidant personality disorder and social anxiety disorder (social phobia), so much so that they may be
alternative conceptualizations of the same or similar conditions. Avoidance also characterizes both avoidant personality disorder and agoraphobia, and they often co-occur.
Other personality disorders and personality traits. Other personality disorders may
be confused with avoidant personality disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differences
in their characteristic features. However, if an individual has personality features that
meet criteria for one or more personality disorders in addition to avoidant personality dis-
order, all can be diagnosed. Both avoidant personality disorder and dependent personality disorder are characterized by feelings of inadequacy, hypersensitivity to criticism, and
a need for reassurance. Although the primary focus of concern in avoidant personality
disorder is avoidance of humiliation and rejection, in dependent personality disorder the
focus is on being taken care of. However, avoidant personality disorder and dependent
personality disorder are particularly likely to co-occur. Like avoidant personality disorder, schizoid personality disorder and schizotypal personality disorder are characterized
by social isolation. However, individuals with avoidant personality disorder want to have
relationships with others and feel their loneliness deeply, whereas those with schizoid or
schizotypal personality disorder may be content with and even prefer their social isolation. Paranoid personality disorder and avoidant personality disorder are both characterized by a reluctance to confide in others. However, in avoidant personality disorder, this
reluctance is attributable more to a fear of being embarrassed or being found inadequate
than to a fear of others' malicious intent.
Many individuals display avoidant personality traits. Only when these traits are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress do they constitute avoidant personality disorder.
Personality change due to another medical condition. Avoidant personality disorder
must be distinguished from personality change due to another medical condition, in
which the traits that emerge are attributable to the effects of another medical condition on
the central nervous system.
Substance use disorders. Avoidant personality disorder must also be distinguished
from symptoms that may develop in association with persistent substance use.
Dependent Personality Disorder
Diagnostic Criteria 301.6(F60.7)
A pervasive and excessive need to be taken care of that leads to submissive and clinging
behavior and fears of separation, beginning by early adulthood and present in a variety of
contexts, as indicated by five (or more) of the following:
1. Has difficulty making everyday decisions without an excessive amount of advice and
reassurance from others.
2. Needs others to assume responsibility for most major areas of his or her life.
3. Has difficulty expressing disagreement with others because of fear of loss of support
or approval. (Note: Do not include realistic fears of retribution.)
4. Has difficulty initiating projects or doing things on his or her own (because of a lack of
self-confidence in judgment or abilities rather than a lack of motivation or energy).
5. Goes to excessive lengths to obtain nurturance and support from others, to the point
of volunteering to do things that are unpleasant.
6. Feels uncomfortable or helpless when alone because of exaggerated fears of being
unable to care for himself or herself.
7. Urgently seeks another relationship as a source of care and support when a close relationship ends.
8. Is unrealistically preoccupied with fears of being left to take care of himself or herself.
Diagnostic Features
The essential feature of dependent personality disorder is a pervasive and excessive need
to be taken care of that leads to submissive and clinging behavior and fears of separation.
This pattern begins by early adulthood and is present in a variety of contexts. The dependent
and submissive behaviors are designed to elicit caregiving and arise from a self-perception
of being unable to function adequately without the help of others.
Individuals with dependent personality disorder have great difficulty making everyday decisions (e.g., what color shirt to wear to work or whether to carry an umbrella) without
an excessive amount of advice and reassurance from others (Criterion 1). These individuals tend to be passive and to allow other people (often a single other person) to take the initiative and assume responsibility for most major areas of their lives (Criterion 2). Adults
with this disorder typically depend on a parent or spouse to decide where they should
live, what kind of job they should have, and which neighbors to befriend. Adolescents
with this disorder may allow their parent(s) to decide what they should wear, with whom
they should associate, how they should spend their free time, and what school or college
they should attend. This need for others to assume responsibility goes beyond age-appropriate and situation-appropriate requests for assistance from others (e.g., the specific
needs of children, elderly persons, and handicapped persons). Dependent personality disorder may occur in an individual who has a serious medical condition or disability, but in
such cases the difficulty in taking responsibility must go beyond what would normally be
associated with that condition or disability.
Because they fear losing support or approval, individuals with dependent personality
disorder often have difficulty expressing disagreement with other individuals, especially
those on whom they are dependent (Criterion 3). These individuals feel so unable to function alone that they will agree with things that they feel are wrong rather than risk losing
the help of those to whom they look for guidance. They do not get appropriately angry at
others whose support and nurturance they need for fear of alienating them. If the individual's concerns regarding the consequences of expressing disagreement are realistic (e.g.,
realistic fears of retribution from an abusive spouse), the behavior should not be considered to be evidence of dependent personality disorder.
Individuals with this disorder have difficulty initiating projects or doing things independently (Criterion 4). They lack self-confidence and believe that they need help to begin
and carry through tasks. They will wait for others to start things because they believe that
as a rule others can do them better. These individuals are convinced that they are incapable
of functioning independently and present themselves as inept and requiring constant assistance. They are, however, likely to function adequately if given the assurance that someone else is supervising and approving. There may be a fear of becoming or appearing to be
more competent, because they may believe that this will lead to abandonment. Because
they rely on others to handle their problems, they often do not leam the skills of independent living, thus perpetuating dependency.
Individuals with dependent personality disorder may go to excessive lengths to obtain
nurturance and support from others, even to the point of volunteering for unpleasant
tasks if such behavior will bring the care they need (Criterion 5). They are willing to submit
to what others want, even if the demands are unreasonable. Their need to maintain an important bond will often result in imbalanced or distorted relationships. They may make extraordinary self-sacrifices or tolerate verbal, physical, or sexual abuse. (It should be noted
that this behavior should be considered evidence of dependent personality disorder only
when it can clearly be established that other options are available to the individual.) Individuals with this disorder feel uncomfortable or helpless when alone, because of their exaggerated fears of being unable to care for themselves (Criterion 6). They will "tag along"
with important others just to avoid being alone, even if they are not interested or involved
in what is happening.
When a close relationship ends (e.g., a breakup with a lover; the death of a caregiver), individuals with dependent personality disorder may urgently seek another relationship to
provide the care and support they need (Criterion 7). Their belief that they are unable to
function in the absence of a close relationship motivates these individuals to become quickly
and indiscriminately attached to another individual. Individuals with this disorder are often
preoccupied with fears of being left to care for themselves (Criterion 8). They see themselves
as so totally dependent on the advice and help of an important other person that they worry
about being abandoned by that person when there are no grounds to justify such fears. To be
considered as evidence of this criterion, the fears must be excessive and unrealistic. For example, an elderly man with cancer who moves into his son's household for care is exhibiting
dependent behavior that is appropriate given this person's life circumstances.
Associated Features Supporting Diagnosis
Individuals with dependent personality disorder are often characterized by pessimism
and self-doubt, tend to belittle their abilities and assets, and may constantly refer to themselves as "stupid." They take criticism and disapproval as proof of their worthlessness and
lose faith in themselves. They may seek overprotection and dominance from others. Occupational functioning may be impaired if independent initiative is required. They may
avoid positions of responsibility and become anxious when faced with decisions. Social relations tend to be limited to those few people on whom the individual is dependent. There
may be an increased risk of depressive disorders, anxiety disorders, and adjustment disorders. Dependent personality disorder often co-occurs with other personality disorders,
especially borderline, avoidant, and histrionic personality disorders. Chronic physical illness or separation anxiety disorder in childhood or adolescence may predispose the individual to the development of this disorder.
Prevalence
Data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions yielded an estimated prevalence of dependent personality disorder of 0.49%, and dependent personality was estimated, based on a probability subsample from Part II of the
National Comorbidity Survey Replication, to be 0.6%.
Deveiopment and Course
This diagnosis should be used with great caution, if at all, in children and adolescents, for
whom dependent behavior may be developmentally appropriate.
Culture-Reiated Diagnostic issues
The degree to which dependent behaviors are considered to be appropriate varies substantially across different age and sociocultural groups. Age and cultural factors need to
be considered in evaluating the diagnostic threshold of each criterion. Dependent behavior should be considered characteristic of the disorder only when it is clearly in excess of
the individual's cultural norms or reflects unrealistic concerns. An emphasis on passivity,
politeness, and deferential treatment is characteristic of some societies and may be misinterpreted as traits of dependent personality disorder. Similarly, societies may differentially foster and discourage dependent behavior in males and females.
Gender-Reiated Diagnostic Issues
In clinical settings, dependent personality disorder has been diagnosed more frequently in
females, although some studies report similar prevalence rates among males and females.
Differential Diagnosis
Other mental disorders and medical conditions. Dependent personality disorder must
be distinguished from dependency arising as a consequence of other mental disorders (e.g.,
depressive disorders, panic disorder, agoraphobia) and as a result of other medical conditions.
Other personality disorders and personality traits. Other personality disorders may be
confused with dependent personality disorder because they have certain features in common. It is therefore important to distinguish among these disorders based on differences in
their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to dependent personality disorder, all
can be diagnosed. Although many personality disorders are characterized by dependent
features, dependent personality disorder can be distinguished by its predominantly submissive, reactive, and clinging behavior. Both dependent personality disorder and borderline
personality disorder are characterized by fear of abandonment; however, the individual
with borderline personality disorder reacts to abandonment with feelings of emotional emptiness, rage, and demands, whereas the individual with dependent personality disorder reacts with increasing appeasement and submissiveness and urgently seeks a replacement
relationship to provide caregiving and support. Borderline personality disorder can further
be distinguished from dependent personality disorder by a typical pattern of unstable and
intense relationships. Individuals with histrionic personality disorder, like those with dependent personality disorder, have a strong need for reassurance and approval and may appear childlike and clinging. However, unlike dependent personality disorder, which is
characterized by self-effacing and docile behavior, histrionic personality disorder is characterized by gregarious flamboyance with active demands for attention. Both dependent
personality disorder and avoidant personality disorder are characterized by feelings of inadequacy, hypersensitivity to criticism, and a need for reassurance; however, individuals
with avoidant personality disorder have such a strong fear of humiliation and rejection that
they withdraw until they are certain they will be accepted. In contrast, individuals with dependent personality disorder have a pattern of seeking and maintaining connections to important others, rather than avoiding and withdrawing from relationships.
Many individuals display dependent personality traits. Orüy when these traits are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress do they constitute dependent personality disorder.
Personality change due to another medical condition. Dependent personality disorder must be distinguished from personality change due to another medical condition, in
which the traits that emerge are attributable to the effects of another medical condition on
the central nervous system.
Substance use disorders. Dependent personality disorder must also be distinguished
from symptoms that may develop in association with persistent substance use.
Obsessive-Compulsive Personality Disorder
Diagnostic Criteria 301.4 (F60.5)
A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and inteφersonal control, at the expense of flexibility, openness, and efficiency, beginning by
early adulthood and present in a variety of contexts, as indicated by four (or more) of the
following:
1. Is preoccupied with details, rules, lists, order, organization, or schedules to the extent
that the major point of the activity is lost.
2. Shows perfectionism that interferes with task completion (e.g., is unable to complete a
project because his or her own overly strict standards are not met).
3. Is excessively devoted to work and productivity to the exclusion of leisure activities and
friendships (not accounted for by obvious economic necessity).
4. Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or
values (not accounted for by cultural or religious identification).
5. Is unable to discard worn-out or worthless objects even when they have no sentimental
value.
6. Is reluctant to delegate tasks or to work with others unless they submit to exactly his
or her way of doing things.
7. Adopts a miserly spending style toward both self and others; money is viewed as
something to be hoarded for future catastrophes.
8. Shows rigidity and stubbornness.
Diagnostic Features
The essential feature of obsessive-compulsive personality disorder is a preoccupation
with orderliness, perfectionism, and mental and interpersonal control, at the expense of
flexibility, openness, and efficiency. This pattern begins by early adulthood and is present
in a variety of contexts.
Individuals with obsessive-compulsive personality disorder attempt to maintain a
sense of control through painstaking attention to rules, trivial details, procedures, lists,
schedules, or form to the extent that the major point of the activity is lost (Criterion 1). They
are excessively careful and prone to repetition, paying extraordinary attention to detail
and repeatedly checking for possible mistakes. They are oblivious to the fact that other
people tend to become very annoyed at the delays and inconveniences that result from this
behavior. For example, when such individuals misplace a list of things to be done, they
will spend an inordinate amount of time looking for the list rather than spending a few
moments re-creating it from memory and proceeding to accomplish the tasks. Time is
poorly allocated, and the most important tasks are left to the last moment. The perfectionism and self-imposed high standards of performance cause significant dysfunction and
distress in these individuals. They may become so involved in making every detail of a
project absolutely perfect that the project is never finished (Criterion 2). For example, the
completion of a written report is delayed by numerous time-consuming rewrites that all
come up short of "perfection." Deadlines are missed, and aspects of the individual's life
that are not the current focus of activity may fall into disarray.
Individuals with obsessive-compulsive personality disorder display excessive devotion
to work and productivity to the exclusion of leisure activities and friendships (Criterion 3).
This behavior is not accounted for by economic necessity. They often feel that they do not
have time to take an evening or a weekend day off to go on an outing or to just relax. They
may keep postponing a pleasurable activity, such as a vacation, so that it may never occur.
When they do take time for leisure activities or vacations, they are very uncomfortable unless they have taken along something to work on so they do not "waste time." There may be
a great concentration on household chores (e.g., repeated excessive cleaning so that "one
could eat off the floor"). If they spend time with friends, it is likely to be in some kind of formally organized activity (e.g., sports). Hobbies or recreational activities are approached as
serious tasks requiring careful organization and hard work to master. The emphasis is on
perfect performance. These individuals turn play into a structured task (e.g., correcting an
infant for not putting rings on the post in the right order; telling a toddler to ride his or her tricycle in a straight line; turning a baseball game into a harsh "lesson").
Individuals with obsessive-compulsive personality disorder may be excessively conscientious, scrupulous, and inflexible about matters of morality, ethics, or values (Criterion 4). They may force themselves and others to follow rigid moral principles and very
strict standards of performance. They may also be mercilessly self-critical about their own
mistakes. Individuals with this disorder are rigidly deferential to authority and rules and
insist on quite literal compliance, with no rule bending for extenuating circumstances. For
example, the individual will not lend a quarter to a friend who needs one to make a telephone call because "neither a borrower nor a lender be" or because it would be "bad" for
the person's character. These qualities should not be accounted for by the individual's cultural or religious identification.
Individuals with this disorder may be unable to discard worn-out or worthless objects,
even when they have no sentimental value (Criterion 5). Often these individuals will admit to being "pack rats." They regard discarding objects as wasteful because "you never
know when you might need something" and will become upset if someone tries to get rid of
the things they have saved. Their spouses or roommates may complain about the amount of
space taken up by old parts, magazines, broken appliances, and so on.
Individuals with obsessive-compulsive personality disorder are reluctant to delegate
tasks or to work with others (Criterion 6). They stubbornly and unreasonably insist that
everything be done their way and that people conform to their way of doing things. They
often give very detailed instructions about how things should be done (e.g., there is one
and only one way to mow the lawn, wash the dishes, build a doghouse) and are surprised
and irritated if others suggest creative alternatives. At other times they may reject offers of
help even when behind schedule because they believe no one else can do it right.
Individuals with this disorder may be miserly and stingy and maintain a standard of
living far below what they can afford, believing that spending must be tightly controlled to
provide for future catastrophes (Criterion 7). Obsessive-compulsive personality disorder
is characterized by rigidity and stubbornness (Criterion 8). Individuals with this disorder
are so concerned about having things done the one "correct" way that they have trouble
going along with anyone else's ideas. These individuals plan ahead in meticulous detail
and are unwilling to consider changes. Totally wrapped up in their own perspective, they
have difficulty acknowledging the viewpoints of others. Friends and colleagues may become frustrated by this constant rigidity. Even when individuals with obsessive-compulsive personality disorder recognize that it may be in their interest to compromise, they
may stubbornly refuse to do so, arguing that it is "the principle of the thing."
Associated Features Supporting Diagnosis
When rules and established procedures do not dictate the correct answer, decision making
may become a time-consuming, often painful process. Individuals with obsessivecompulsive personality disorder may have such difficulty deciding which tasks take priority or what is the best way of doing some particular task that they may never get started
on anything. They are prone to become upset or angry in situations in which they are not
able to maintain control of their physical or interpersonal environment, although the anger is typically not expressed directly. For example, an individual may be angry when service in a restaurant is poor, but instead of complaining to the management, the individual
ruminates about how much to leave as a tip. C3n other occasions, anger may be expressed
with righteous indignation over a seemingly minor matter. Individuals with this disorder
may be especially attentive to their relative status in dominance-submission relationships
and may display excessive deference to an authority they respect and excessive resistance
to authority they do not respect.
Individuals with this disorder usually express affection in a highly controlled or stilted
fashion and may be very uncomfortable in the presence of others who are emotionally expressive. Their everyday relationships have a formal and serious quality, and they may be
stiff in situations in which others would smile and be happy (e.g., greeting a lover at the
airport). They carefully hold themselves back until they are sure that whatever they say
will be perfect. They may be preoccupied with logic and intellect, and intolerant of affective behavior in others. They often have difficulty expressing tender feelings, rarely paying compliments. Individuals with this disorder may experience occupational difficulties
and distress, particularly when confronted with new situations that demand flexibility
and compromise.
Individuals with anxiety disorders, including generalized anxiety disorder, social anxiety disorder (social phobia), and specific phobias, and obsessive-compulsive disorder (OCD)
have an increased likelihood of having a personality disturbance that meets criteria for obsessive-compulçive personality disorder. Even so, it appears that the majority of individuals with OCD do not have a pattern of behavior that meets criteria for this personality
disorder. Many of the features of obsessive-compulsive personality disorder overlap with
"type A" personality characteristics (e.g., preoccupation with work, competitiveness, time
urgency), and these features may be present in people at risk for myocardial infarction.
There may be an association between obsessive-compulsive personality disorder and depressive and bipolar disorders and eating disorders.
Prevalence
Obsessive-compulsive personality disorder is one of the most prevalent personality disorders in the general population, with estimated prevalence ranging from 2.1% to 7.9%.
Culture-Related Diagnostic Issues
In assessing an individual for obsessive-compulsive personality disorder, the clinician
should not include those behaviors that reflect habits, customs, or interpersonal styles that
are culturally sanctioned by the individual's reference group. Certain cultures place substantial emphasis on work and productivity; the resulting behaviors in members of those
societies need not be considered indications of obsessive-compulsive personality disorder.
Gender-Related Diagnostic Issues
In systematic studies, obsessive-compulsive personality disorder appears to be diagnosed
about twice as often among males.
Differential Diagnosis
Obsessive-compulsive disorder. Despite the similarity in names, OCD is usually easily
distinguished from obsessive-compulsive personality disorder by the presence of true obsessions and compulsions in OCD. When criteria for both obsessive-compulsive personality disorder and OCD are met, both diagnoses should be recorded.
Hoarding disorder. A diagnosis of hoarding disorder should be considered especially
when hoarding is extreme (e.g., accumulated stacks of worthless objects present a fire hazard and make it difficult for others to walk through the house). When criteria for both obsessive-compulsive personality disorder and hoarding disorder are met, both diagnoses
should be recorded.
Other personality disorders and personality traits. Other personality disorders may
be confused with obsessive-compulsive personality disorder because they have certain
features in common. It is, therefore, important to distinguish among these disorders based
on differences in their characteristic features. However, if an individual has personality
features that meet criteria for one or more personality disorders in addition to obsessivecompulsive personality disorder, all can be diagnosed. Individuals with narcissistic personality disorder may also profess a commitment to perfectionism and believe that others
cannot do things as well, but these individuals are more likely to believe that they have
achieved perfection, whereas those with obsessive-compulsive personahty disorder are
usually self-critical. Individuals with narcissistic or antisocial personality disorder lack
generosity but will indulge themselves, whereas those with obsessive-compulsive personality disorder adopt a miserly spending style toward both self and others. Both schizoid
personality disorder and obsessive-compulsive personality disorder may be characterized
by an apparent formality and social detachment. In obsessive-compulsive personality disorder, this stems from discomfort with emotions and excessive devotion to work, whereas
in schizoid personality disorder there is a fundamental lack of capacity for intimacy.
Obsessive-compulsive personality traits in moderation may be especially adaptive, particularly in situations that reward high performance. Only when these traits are inflexible,
maladaptive, and persisting and cause significant functional impairment or subjective distress do they constitute obsessive-compulsive personality disorder.
Personality change due to another medical condition. Obsessive-compulsive personality disorder must be distinguished from personality change due to another medical condition, in which the traits emerge attributable to the effects of another medical condition
on the central nervous system.
Substance use disorders. Obsessive-compulsive personality disorder must also be distinguished from symptoms that may develop in association with persistent substance use.
Other Personality Disorders
Personality Change
Due to Another Medical Condition
Diagnostic Criteria 310.1 (F07.0)
A. A persistent personality disturbance that represents a change fronn the individual’s previous characteristic personality pattern.
Note: In children, the disturbance involves a marked deviation from normal development or a significant change in the child’s usual behavior patterns, lasting at least
1 year.
B. There is evidence from the history, physical examination, or laboratory findings that the
disturbance is the direct pathophysiological consequence of another medical condition.
C. The disturbance is not better explained by another mental disorder (including another
mental disorder due to another medical condition).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify whether:
Labile type: If the predominant feature is affective lability.
Disinhibited type: If the predominant feature is poor impulse control as evidenced by
sexual indiscretions, etc.
Aggressive type: If the predominant feature is aggressive behavior.
Apathetic type: If the predominant feature is marked apathy and indifference.
Paranoid type: If the predominant feature is suspiciousness or paranoid ideation.
Other type: If the presentation is not characterized by any of the above subtypes.
Combined type: If more than one feature predominates in the clinical picture.
Unspecified type
Coding note: Include the name of the other medical condition (e.g., 310.1 [F07.0] personality change due to temporal lobe epilepsy). The other medical condition should be coded
and listed separately immediately before the personality disorder due to another medical
condition (e.g., 345.40 [G40.209] temporal lobe epilepsy; 310.1 [F07.0] personality
change due to temporal lobe epilepsy).
Subtypes
The particular {Personality change can be specified by indicating the symptom presentation that predominates in the clinical presentation.
Diagnostic Features
The essential feature of a personality change due to another medical condition is a persistent personality disturbance that is judged to be due to the direct pathophysiological effects of a medical condition. The personality disturbance represents a change from the
individual's previous characteristic personality pattern. In children, this condition may be
manifested as a marked deviation from normal development rather than as a change in a
stable personality pattern (Criterion A). There must be evidence from the history, physical
examination, or laboratory findings that the personality change is the direct physiological
consequence of another medical condition (Criterion B). The diagnosis is not given if the
disturbance is better explained by another mental disorder (Criterion C). The diagnosis is
not given if the disturbance occurs exclusively during the course of a delirium (Criterion
D). The disturbance must also cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning (Criterion E).
Common manifestations of the personality change include affective instability, poor
impulse control, outbursts of aggression or rage grossly out of proportion to any precipitating psychosocial stressor, marked apathy, suspiciousness, or paranoid ideation. The
phenomenology of the change is indicated using the subtypes listed in the criteria set. An
individual with the disorder is often characterized by others as "not himself [or herself]."
Although it shares the term "personality" with the other personality disorders, this diagnosis is distinct by virtue of its specific etiology, different phenomenology, and more variable onset and course.
The clinical presentation in a given individual may depend on the nature and localization of the pathological process. For example, injury to the frontal lobes may yield symptoms such as lack of judgment or foresight, facetiousness, disinhibition, and euphoria.
Right hemisphere strokes have often been shown to evoke personality changes in association with unilateral spatial neglect, anosognosia (i.e., inability of the individual to
recognize a bodily or functional deficit, such as the existence of hemiparesis), motor impersistence, and other neurological deficits.
Associated Features Supporting Diagnosis
A variety of neurological and other medical conditions may cause personality changes,
including central nervous system neoplasms, head trauma, cerebrovascular disease,
Huntington's disease, epilepsy, infectious conditions with central nervous system involvement (e.g., HIV), endocrine conditions (e.g., hypothyroidism, hypo- and hyperadrenocorticism), and autoimmune conditions with central nervous system involvement (e.g.,
systemic lupus erythematosus). The associated physical examination findings, laboratory
findings, and patterns of prevalence and onset reflect those of the neurological or other
medical condition involved.
Differentiai Diagnosis
Chronic medical conditions associated with pain and disability. Chronic medical conditions associated with pain and disability can also be associated with changes in personality. The diagnosis of personality change due to another medical condition is given only
if a direct pathophysiological mechanism can be established. This diagnosis is not given if
the change is due to a behavioral or psychological adjustment or response to another medical condition (e.g., dependent behaviors that result from a need for the assistance of others
following a severe head trauma, cardiovascular disease, or dementia).
Delirium or major neurocognitive disorder. Personality change is a frequently associated
feature of a delirium or major neurocognitive disorder. A separate diagnosis of personality change due to another medical condition is not given if the change occurs exclusively
during the course of a delirium. However, the diagnosis of personality change due to another medical condition may be given in addition to the diagnosis of major neurocognitive
disorder if the personality change is a prominent part of the clinical presentation.
Another mental disorder due to another medical condition. The diagnosis of personality change due to another medical condition is not given if the disturbance is better explained by another mental disorder due to another medical condition (e.g., depressive
disorder due to brain tumor).
Substance use disorders. Personality changes may also occur in the context of substance
use disorders, especially if the disorder is long-standing. The clinician should inquire carefully
about the nature and extent of substance use. If the clinician wishes to indicate an etiological relationship between the personality change and substance use, the unspecified category for the
specific substance (e.g., unspecified stimulant-related disorder) can be used.
Other mental disorders. Marked personality changes may also be an associated feature
of other mental disorders (e.g., schizophrenia; delusional disorder; depressive and bipolar
disorders; other specified and unspecified disruptive behavior, impulse-control, and conduct disorders; panic disorder). However, in these disorders, no specific physiological factor is judged to be etiologically related to the personality change.
Other personality disorders. Personality change due to another medical condition can
be distinguished from a personality disorder by the requirement for a clinically significant
change from baseline personality functioning and the presence of a specific etiological
medical condition.
Other Specified Personality Disorder
301.89 (F60.89)
This category applies to presentations in wliich symptoms characteristic of a personality
disorder that cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning predominate but do not meet the full criteria for any of
the disorders in the personality disorders diagnostic class. The other specified personality
disorder category is used in situations in which the clinician chooses to communicate the
specific reason that the presentation does not meet the criteria for any specific personality
disorder. This is done by recording “other specified personality disorder” followed by the
specific reason (e.g., “mixed personality features”).
Unspecified Personality Disorder
301.9 (F60.9)
This category applies to presentations in which symptoms characteristic of a personality
disorder that cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning predominate but do not meet the full criteria for any of
the disorders in the personality disorders diagnostic class. The unspecified personality
disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific personality disorder, and includes presentations in which there is insufficient information to make a more specific diagnosis.
ParapKilic
Disorders
Psrsphilic disorders included in this manual are voyeuristic disorder (spying on
others in private activities), exhibitionistic disorder (exposing the genitals), frotteuristic
disorder (touching or rubbing against a nonconsenting individual), sexual masochism
disorder (undergoing humiliation, bondage, or suffering), sexual sadism disorder (inflicting humiliation, bondage, or suffering), pedophilic disorder (sexual focus on children), fetishistic disorder (using nonliving objects or having a highly specific focus on nongenital
body parts), and transvestic disorder (engaging in sexually arousing cross-dressing).
These disorders have traditionally been selected for specific listing and assignment of explicit diagnostic criteria in DSM for two main reasons: they are relatively common, in relation to other paraphilic disorders, and some of them entail actions for their satisfaction
that, because of their noxiousness or potential harm to others, are classed as criminal offenses. The eight listed disorders do not exhaust the list of possible paraphilic disorders.
Many dozens of distinct paraphilias have been identified and named, and almost any of
them could, by virtue of its negative consequences for the individual or for others, rise to
the level of a paraphilic disorder. The diagnoses of the other specified and unspecified
paraphilic disorders are therefore indispensable and will be required in many cases.
In this chapter, the order of presentation of the listed paraphilic disorders generally
corresponds to common classification schemes for these conditions. The first group of
disorders is based on anomalous activity preferences. These disorders are subdivided into
courtship disorders, which resemble distorted components of human courtship behavior
(voyeuristic disorder, exhibitionistic disorder, and frotteuristic disorder), and algolagnie
disorders, which involve pain and suffering (sexual masochism disorder and sexual sadism
disorder). The second group of disorders is based on anomalous target preferences. These
disorders include one directed at other humans (pedophilic disorder) and two directed
elsewhere (fetishistic disorder and transvestic disorder).
The term paraphilia denotes any intense and persistent sexual interest other than sexual
interest in genital stimulation or preparatory fondling with phenotypically normal, physically mature, consenting human partners. In some circumstances, the criteria "intense
and persistent" may be difficult to apply, such as in the assessment of persons who are
very old or medically ill and who may not have "intense" sexual interests of any kind. In
such circumstances, the term paraphilia may be defined as any sexual interest greater than
or equal to normophilic sexual interests. There are also specific paraphilias that are generally better described as preferential sexual interests than as intense sexual interests.
Some paraphilias primarily concern the individual's erotic activities, and others primarily concern the individual's erotic targets. Examples of the former would include intense and persistent interests in spanking, whipping, cutting, binding, or strangulating
another person, or an interest in these activities that equals or exceeds the individual's interest in copulation or equivalent interaction with another person. Examples of the latter
would include intense or preferential sexual interest in children, corpses, or amputees (as
a class), as well as intense or preferential interest in nonhuman animals, such as horses or
dogs, or in inanimate objects, such as shoes or articles made of rubber.
A paraphilic disorder is a paraphilia that is currently causing distress or impairment to the
individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to
others. A paraphilia is a necessary but not a sufficient condition for having a paraphilic disorder, and a paraphilia by itself does not necessarily justify or require clinical intervention.
In the diagnostic criteria set for each of the listed paraphilic disorders. Criterion A specifies
the qualitative nature of the paraphilia (e.g., an erotic focus on children or on exposing tiie genitals to strangers), and Criterion B specifies the negative consequences of the paraphilia (i.e.,
distress, impairment, or harm to others). In keeping with the distinction between paraphilias
and paraphilic disorders, the term diagnosis should be reserved for individuals who meet both
Criteria A and B (i.e., individuals who have a paraphilic disorder). If an individual meets Criterion A but not Criterion B for a particular paraphilia—a circumstance that might arise when
a benign paraphilia is discovered during the clinical investigation of some other condition—
then the individual may be said to have that paraphilia but not a paraphilic disorder.
It is not rare for an individual to manifest two or more paraphilias. In some cases, the paraphilic foci are closely related and the connection between the paraphilias is intuitively comprehensible (e.g., foot fetishism and shoe fetishism). In other cases, the connection between the
paraphilias is not obvious, and the presence of multiple paraphilias may be coincidental or else
related to some generalized vulnerability to anomalies of psychosexual development. In any
event, comorbid diagnoses of separate paraphilic disorders may be warranted if more than
one paraphilia is causing suffering to the individual or harm to others.
Because of the two-pronged nature of diagnosing paraphilic disorders, clinician-rated
or self-rated measures and severity assessments could address either the strength of the
paraphilia itself or the seriousness of its consequences. Although the distress and impairment stipulated in the Criterion B are special in being the immediate or ultimate result of
the paraphilia and not primarily the result of some other factor, the phenomena of reactive
depression, anxiety, guilt, poor work history, impaired social relations, and so on are not
unique in themselves and may be quantified with multipurpose measures of psychosocial
functioning or quality of life.
The most widely applicable framework for assessing the strength of a paraphilia itself
is one in which examinees' paraphilic sexual fantasies, urges, or behaviors are evaluated in
relation to their normophilic sexual interests and behaviors. In a clinical interview or on
self-administered questionnaires, examinees can be asked whether their paraphilic sexual
fantasies, urges, or behaviors are weaker than, approximately equal to, or stronger than
their normophilic sexual interests and behaviors. This same type of comparison can be,
and usually is, employed in psychophysiological measures of sexual interest, such as penile plethysmography in males or viewing time in males and females.
Voyeuristic Disorder
Diagnostic Criteria 302.82 (F65.3)
A. Over a period of at least 6 months, recurrent and intense sexual arousal from observing an unsuspecting person who is naked, in the process of disrobing, or engaging in
sexual activity, as manifested by fantasies, urges, or behaviors.
B. The individual has acted on these sexual urges with a nonconsenting person, or the
sexual urges or fantasies cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
0. The individual experiencing the arousal and/or acting on the urges is at least 18 years
of age.
Specify if:
In a controlled environment: This specifier is primarily applicable to individuals living
in institutional or other settings where opportunities to engage in voyeuristic behavior
are restricted.
In full remission: The individual lias not acted on the urges with a nonconsenting person, and there has been no distress or impairment in social, occupational, or other areas of functioning, for at least 5 years while in an uncontrolled environment.
Specifiers
The "in full remission" specifier does not address the continued presence or absence of
voyeurism per se, which may still be present after behaviors and distress have remitted.
Diagnostic Features
The diagnostic criteria for voyeuristic disorder can apply both to individuals who more or less
freely disclose this paraphilic interest and to those who categorically deny any sexual arousal
from observing an unsuspecting person who is naked, disrobing, or engaged in sexual activity
despite substantial objective evidence to the contrary. If disclosing individuals also report distress or psychosocial problems because of their voyeuristic sexual preferences, they could be
diagnosed with voyeuristic disorder. On the other hand, if they declare no distress, demonstrated by lack of anxiety, obsessions, guilt, or shame, about these paraphilic impulses and are
not impaired in other important areas of functioning because of tids sexual interest, and their
psychiatric or legal histories indicate that they do not act on it, they could be ascertained as
having voyeuristic sexual interest but should not be diagnosed with voyeuristic disorder.
Nondisclosing individuals include, for example, individuals known to have been spying repeatedly on unsuspecting persons who are naked or engaging in sexual activity on
separate occasions but who deny any urges or fantasies concerning such sexual behavior,
and who may report that known episodes of watching unsuspecting naked or sexually active persons were all accidental and nonsexual. Others may disclose past episodes of observing unsuspecting naked or sexually active persons but contest any significant or
sustained sexual interest in this behavior. Since these individuals deny having fantasies or
impulses about watching others nude or involved in sexual activity, it follows that they
would also reject feeling subjectively distressed or socially impaired by such impulses. Despite their nondisclosing stance, such individuals may be diagnosed with voyeuristic disorder. Recurrent voyeuristic behavior constitutes sufficient support for voyeurism (by
fulfilling Criterion A) and simultaneously demonstrates that this paraphilically motivated
behavior is causing harm to others (by fulfilling Criterion B).
"Recurrent" spying on unsuspecting persons who are naked or engaging in sexual activity (i.e., multiple victims, each on a separate occasion) may, as a general rule, be interpreted as three or more victims on separate occasions. Fewer victims can be interpreted as
satisfying this criterion if there were multiple occasions of watching the same victim or if
there is corroborating evidence of a distinct or preferential interest in secret watching of
naked or sexually active unsuspecting persons. Note that multiple victims, as suggested
earlier, are a sufficient but not a necessary condition for diagnosis; the criteria may also be
met if the individual acknowledges intense voyeuristic sexual interest.
The Criterion A time frame, indicating that signs or symptoms of voyeurism must have
persisted for at least 6 months, should also be understood as a general guideline, not a
strict threshold, to ensure that the sexual interest in secretly watching unsuspecting naked
or sexually active others is not merely transient.
Adolescence and puberty generally increase sexual curiosity and activity. To alleviate
the risk of pathologizing normative sexual interest and behavior during pubertal adolescence, the minimum age for the diagnosis of voyeuristic disorder is 18 years (Criterion C).
Prevalence
Voyeuristic acts are the most common of potentially law-breaking sexual behaviors. The
population prevalence of voyeuristic disorder is unknown. However, based on voyeuris
tic sexual acts in nonclinical samples, the highest possible lifetime prevalence for voyeuristic disorder is approximately 12% in males and 4% in females.
Development and Course
Adult males with voyeuristic disorder often first become aware of their sexual interest in
secretly watching unsuspecting persons during adolescence. However, the minimum age
for a diagnosis of voyeuristic disorder is 18 years because there is substantial difficulty in
differentiating it from age-appropriate puberty-related sexual curiosity and activity. The
persistence of voyeurism over time is unclear. Voyeuristic disorder, however, per definition requires one or more contributing factors that may change over time with or without
treatment: subjective distress (e.g., guilt, shame, intense sexual frustration, loneliness),
psychiatric morbidity, hypersexuality, and sexual impulsivity; psychosocial impairment;
and/or the propensity to act out sexually by spying on unsuspecting naked or sexually active persons. Therefore, the course of voyeuristic disorder is likely to vary with age.
Risk and Prognostic Factors
Iemperamental. Voyeurism is a necessary precondition for voyeuristic disorder; hence,
risk factors for voyeurism should also increase the rate of voyeuristic disorder.
Environmental. Childhood sexual abuse, substance misuse, and sexual preoccupation/
hypersexuality have been suggested as risk factors, although the causal relationship to
voyeurism is uncertain and the specificity unclear.
Gender-Related Diagnostic Issues
Voyeuristic disorder is very uncommon among females in clinical settings, while the maleto-female ratio for single sexually arousing voyeuristic acts might be 3:1.
Differential Diagnosis
Conduct disorder and antisocial personality disorder. Conduct disorder in adolescents
and antisocial personality disorder would be characterized by additional norm-breaking
and antisocial behaviors, and the specific sexual interest in secretly watching unsuspecting others who are naked or engaging in sexual activity should be lacking.
Substance use disorders. Substance use disorders might involve single voyeuristic episodes by intoxicated individuals but should not involve the typical sexual interest in secretly watching unsuspecting persons being naked or engaging in sexual activity. Hence,
recurrent voyeuristic sexual fantasies, urges, or behaviors that occur also when the individual is not intoxicated suggest that voyeuristic disorder might be present.
Comorbidity
Known comorbidities in voyeuristic disorder are largely based on research with males
suspected of or convicted for acts involving the secret watching of unsuspecting nude or
sexually active persons. Hence, these comorbidities might not apply to all individuals with
voyeuristic disorder. Conditions that occur comorbidly with voyeuristic disorder include
hypersexuality and other paraphilic disorders, particularly exhibitionistic disorder. Depressive, bipolar, anxiety, and substance use disorders; attention-deficit/hyperactivity
disorder; and conduct disorder and antisocial personality disorder are also frequent comorbid conditions.
Exhibitionistic Disorder
Diagnostic Criteria 302.4 (F65.2)
A. Over a period of at least 6 months, recurrent and intense sexual arousal from the exposure of one’s genitals to an unsuspecting person, as manifested by fantasies, urges,
or behaviors.
B. The individual has acted on these sexual urges with a nonconsenting person, or the
sexual urges or fantasies cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Specify whether:
Sexually aroused by exposing genitals to prepubertal children
Sexually aroused by exposing genitals to physically mature individuals
Sexually aroused by exposing genitals to prepubertal children and to physically
mature individuals
Specify if;
In a controlled environment: This specifier is primarily applicable to individuals living in
institutional or other settings where opportunities to expose one’s genitals are restricted.
In full remission: The individual has not acted on the urges with a nonconsenting person, and there has been no distress or impairment in social, occupational, or other areas of functioning, for at least 5 years while in an uncontrolled environment.
Subtypes
The subtypes for exhibitionistic disorder are based on the age or physical maturity of the nonconsenting individuals to whom the individual prefers to expose his or her genitals. The nonconsenting individuals could be prepubescent children, adults, or both. This specifier should
help draw adequate attention to characteristics of victims of individuals with exhibitionistic
disorder to prevent co-occurring pedophilic disorder from being overlooked. However, indications that the individual with exhibitionistic disorder is sexually attracted to exposing his or
her genitals to children should not preclude a diagnosis of pedophilic disorder.
Specifiers
The "in full remission" specifier does not address the continued presence or absence of exhibitionism per se, which may still be present after behaviors and distress have remitted.
Diagnostic Features
The diagnostic criteria for exhibitionistic disorder can apply both to individuals who more or
less freely disclose this paraphilia and to those who categorically deny any sexual attraction to
exposing their genitals to unsuspecting persons despite substantial objective evidence to the
contrary. If disclosing individuals also report psychosocial difficulties because of their sexual
attractions or preferences for exposing, they may be diagnosed with exhibitionistic disorder. In
contrast, if they declare no distress (exemplified by absence of anxiety, obsessions, and guilt or
shame about these paraphilic impulses) and are not impaired by this sexual interest in other
important areas of functioning, and their self-reported, psychiatric, or legal histories indicate
that they do not act on them, they could be ascertained as having exhibitionistic sexual interest
but not be diagnosed with exhibitionistic disorder.
Examples of nondisclosing individuals include those who have exposed themselves
repeatedly to unsuspecting persons on separate occasions but who deny any urges or fan
tasies about such sexual behavior and who report that known episodes of exposure were
all accidental and nonsexual. Others may disclose past episodes of sexual behavior involving genital exposure but refute any significant or sustained sexual interest in such behavior. Since these individuals deny having urges or fantasies involving genital exposure, it
follows that they would also deny feeling subjectively distressed or socially impaired by
such impulses. Such individuals may be diagnosed with exhibitionistic disorder despite
their negative self-report. Recurrent exhibitionistic behavior constitutes sufficient support
for exhibitionism (Criterion A) and simultaneously demonstrates that this paraphilically
motivated behavior is causing harm to others (Criterion B).
"Recurrent" genital exposure to unsuspecting others (i.e., multiple victims, each on a
separate occasion) may, as a general rule, be interpreted as three or more victims on separate occasions. Fewer victims can be interpreted as satisfying this criterion if there were
multiple occasions of exposure to the same victim, or if there is corroborating evidence of
a strong or preferential interest in genital exposure to unsuspecting persons. Note that
multiple victims, as suggested earlier, are a sufficient but not a necessary condition for diagnosis, as criteria may be met by an individual's acknowledging intense exhibitionistic
sexual interest with distress and/or impairment.
The Criterion A time frame, indicating that signs or symptoms of exhibitionism must
have persisted for at least 6 months, should also be understood as a general guideline, not
a strict threshold, to ensure that the sexual interest in exposing one's genitals to unsuspecting others is not merely transient. This might be expressed in clear evidence of repeated
behaviors or distress over a nontransient period shorter than 6 months.
Prevalence
The prevalence of exhibitionistic disorder is unknown. However, based on exhibitionistic
sexual acts in nonclinical or general populations, the highest possible prevalence for exhibitionistic disorder in the male population is 2%-4%. The prevalence of exhibitionistic disorder in females is even more uncertain but is generally believed to be much lower than in
males.
Development and Course
Adult males with exhibitionistic disorder often report that they first became aware of sexual interest in exposing their genitals to unsuspecting persons during adolescence, at a
somewhat later time than the typical development of normative sexual interest in women
or men. Although there is no minimum age requirement for the diagnosis of exhibitionistic disorder, it may be difficult to differentiate exhibitionistic behaviors from age-appropriate sexual curiosity in adolescents. Whereas exhibitionistic impulses appear to emerge
in adolescence or early adulthood, very little is known about persistence over time. By definition, exhibitionistic disorder requires one or more contributing factors, which may
change over time with or without treatment; subjective distress (e.g., guilt, shame, intense
sexual frustration, loneliness), mental disorder comorbidity, hypersexuality, and sexual
impulsivity; psychosocial impairment; and/or the propensity to act out sexually by exposing the genitals to unsuspecting persons. Therefore, the course of exhibitionistic disorder
is likely to vary with age. As with other sexual preferences, advancing age may be associated with decreasing exhibitionistic sexual preferences and behavior.
Risk and Prognostic Factors
Temperamental. Since exhibitionism is a necessary precondition for exhibitionistic disorder, risk factors for exhibitionism should also increase the rate of exhibitionistic disorder. Antisocial history, antisocial personality disorder, alcohol misuse, and pedophilic
sexual preference might increase risk of sexual recidivism in exhibitionistic offenders.
Hence, antisocial personality disorder, alcohol use disorder, and pedophilic interest may
be considered ri^k factors for exhibitionistic disorder in males with exhibitionistic sexual
preferences.
Environmental. Childhood sexual and emotional abuse and sexual preoccupation/hypersexuality have been suggested as risk factors for exhibitionism, although the causal relationship to exhibitionism is uncertain and the specificity unclear.
Gender-Related Diagnostic issues
Exhibitionistic disorder is highly unusual in females, whereas single sexually arousing exhibitionistic acts might occur up to half as often among women compared with men.
Functionai Consequences of Exiiibitionistic Disorder
The functional consequences of exhibitionistic disorder have not been addressed in research involving individuals who have not acted out sexually by exposing their genitals to
unsuspecting strangers but who fulfill Criterion B by experiencing intense emotional distress over these preferences.
Differentiai Diagnosis
Potential differential diagnoses for exhibitionistic disorder sometimes occur also as comorbid disorders. Therefore, it is generally necessary to evaluate the evidence for exhibitionistic disorder and other possible conditions as separate questions.
Conduct disorder and antisocial personality disorder. Conduct disorder in adolescents
and antisocial personality disorder would be characterized by additional norm-breaking and
antisocial behaviors, and the specific sexual interest in exposing the genitals should be lacking.
Substance use disorders. Alcohol and substance use disorders might involve single
exhibitionistic episodes by intoxicated individuals but should not involve the typical sexual interest in exposing the genitals to unsuspecting persons. Hence, recurrent exhibitionistic sexual fantasies, urges, or behaviors that occur also when the individual is not
intoxicated suggest that exhibitionistic disorder might be present.
Comorbidity
Known comorbidities in exhibitionistic disorder are largely based on research with individuals (almost all males) convicted for criminal acts involving genital exposure to nonconsenting individuals. Hence, these comorbidities might not apply to all individuals who
qualify for a diagnosis of exhibitionistic disorder. Conditions that occur comorbidly with
exhibitionistic disorder at high rates include depressive, bipolar, anxiety, and substance
use disorders; hypersexuality; attention-deficit/hyperactivity disorder; other paraphilic
disorders; and antisocial personality disorder.
Frotteuristic Disorder
Diagnostic Criteria 302.89 (F65.81)
A. Over a period of at least 6 months, recurrent and intense sexual arousal from touching
or rubbing against a nonconsenting person, as manifested by fantasies, urges, or behaviors.
B. The individual has acted on these sexual urges with a nonconsenting person, or the
sexual urges or fantasies cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Specify if:
In a controlled environment: This specifier is primarily applicable to individuals living
in institutional or other settings where opportunities to touch or rub against a nonconsenting person are restricted.
In full remission: The individual has not acted on the urges with a nonconsenting person, and there has been no distress or impairment in social, occupational, or other areas of functioning, for at least 5 years while in an uncontrolled environment.
Specifiers
The "in remission" specifier does not address the continued presence or absence of frotteurism per se, which may still be present after behaviors and distress have remitted.
Diagnostic Features
The diagnostic criteria for frotteuristic disorder can apply both to individuals who relatively
freely disclose this paraphilia and to those who firmly deny any sexual attraction from touching or rubbing against a nonconsenting individual regardless of considerable objective evidence to the contrary. If disclosing individuals also report psychosocial impairment due to
their sexual preferences for touching or rubbing against a nonconsenting individual, they
could be diagnosed with frotteuristic disorder. In contrast, if they declare no distress (demonstrated by lack of anxiety, obsessions, guilt, or shame) about these paraphilic impulses and are
not impaired in other important areas of functioning because of this sexual interest, and their
psychiatric or legal histories indicate that they do not act on it, they could be ascertained as
having frotteuristic sexual interest but should not be diagnosed with frotteuristic disorder.
Nondisclosing individuals include, for instance, individuals known to have been
touching or rubbing against nonconsenting individuals on separate occasions but who
contest any urges or fantasies concerning such sexual behavior. Such individuals may report that identified episodes of touching or rubbing against an unwilling individual were
all unintentional and nonsexual. Others may disclose past episodes of touching or rubbing
against nonconsenting individuals but contest any major or persistent sexual interest in
this. Since these individuals deny having fantasies or impulses about touching or rubbing,
they would consequently reject feeling distressed or psychosocially impaired by such
impulses. Despite their nondisclosing position, such individuals may be diagnosed with
frotteuristic disorder. Recurrent frotteuristic behavior constitutes satisfactory support for
frotteurism (by fulfilling Criterion A) and concurrently demonstrates that this paraphilically motivated behavior is causing harm to others (by fulfilling Criterion B).
"Recurrent" touching or rubbing against a nonconsenting individual (i.e., multiple victims, each on a separate occasion) may, as a general rule, be inteφreted as three or more victims on separate occasions. Fewer victims can be inteφreted as satisfying this criterion if
there were multiple occasions of touching or rubbing against the same unwilling individual, or corroborating evidence of a strong or preferential interest in touching or rubbing
against nonconsenting individuals. Note that multiple victims are a sufficient but not a necessary condition for diagnosis; criteria may also be met if the individual acknowledges intense frotteuristic sexual interest with clinically significant distress and/or impairment.
The Criterion A time frame, indicating that signs or symptoms of frotteurism must persist
for at least 6 months, should also be inteφreted as a general guideline, not a strict threshold, to
ensure that the sexual interest in touching or rubbing against a nonconsenting individual is not
transient. Hence, the duration part of Criterion A may also be met if there is clear evidence of
recurrent behaviors or distress over a shorter but nontransient time period.
Prevaience
Frotteuristic acts, including the uninvited sexual touching of or rubbing against another
individual, may occur in up to 30% of adult males in the general population. Approximately
10%-14% of adult males seen in outpatient settings for paraphilic disorders and hypersexuality have a presentation that meets diagnostic criteria for frotteuristic disorder. Hence,
whereas the population prevalence of frotteuristic disorder is unknown, it is not likely that
it exceeds the rate found in selected clinical settings.
Development and Course
Adult males with frotteuristic disorder often report first becoming aware of their sexual interest in surreptitiously touching unsuspecting persons during late adolescence or emerging
adulthood. However, children and adolescents may also touch or rub against unwilling others in the absence of a diagnosis of frotteuristic disorder. Although there is no minimum age
for the diagnosis, frotteuristic disorder can be difficult to differentiate from conduct-disordered behavior without sexual motivation in individuals at younger ages. The persistence of
frotteurism over time is unclear. Frotteuristic disorder, however, by definition requires one
or more contributing factors that may change over time with or without treatment: subjective distress (e.g., guilt, shame, intense sexual frustration, loneliness); psychiatric morbidity;
hypersexuality and sexual impulsivity; psychosocial impairment; and/or the propensity to
act out sexually by touching or rubbing against unconsenting persons. Therefore, the course
of frotteuristic disorder is likely to vary with age. As with other sexual preferences, advancing age may be associated with decreasing frotteuristic sexual preferences and behavior.
Risk and Prognostic Factors
Temperamental. Nonsexual antisocial behavior and sexual preoccupation/hypersexuality
might be nonspecific risk factors, although the causal relationship to frotteurism is uncertain
and the specificity unclear. However, frotteurism is a necessary precondition for frotteuristic
disorder, so risk factors for frotteurism should also increase the rate of frotteuristic disorder.
Gender-Related Diagnostic Issues
There appear to be substantially fewer females with frotteuristic sexual preferences than
males.
Differential Diagnosis
Conduct disorder and antisocial personality disorder. Conduct disorder in adolescents
and antisocial personality disorder would be characterized by additional norm-breaking
and antisocial behaviors, and the specific sexual interest in touching or rubbing against a
nonconsenting individual should be lacking.
Substance use disorders. Substance use disorders, particularly those involving stimulants such as cocaine and amphetamines, might involve single frotteuristic episodes by intoxicated individuals but should not involve the typical sustained sexual interest in
touching or rubbing against unsuspecting persons. Hence, recurrent frotteuristic sexual
fantasies, urges, or behaviors that occur also when the individual is not intoxicated suggest that frotteuristic disorder might be present.
Comorbidity
Known comorbidities in frotteuristic disorder are largely based on research with males
suspected of or convicted for criminal acts involving sexually motivated touching of or
rubbing against a nonconsenting individual. Hence, these comorbidities might not apply
to other individuals with a diagnosis of frotteuristic disorder based on subjective distress
over their sexual interest. Conditions that occur comorbidly with frotteuristic disorder include hypersexuality and other paraphilic disorders, particularly exhibitionistic disorder
and voyeuristic disorder. Conduct disorder, antisocial personality disorder, depressive
disorders, bipolar disorders, anxiety disorders, and substance use disorders also co-occur.
Potential differential diagnoses for frotteuristic disorder sometimes occur also as comorbid disorders. Therefore, it is generally necessary to evaluate the evidence for frotteuristic
disorder and possible comorbid conditions as separate questions.
Sexual Masochism Disorder
Diagnostic Criteria 302.83 (F65.51)
A. Over a period of at least 6 months, recurrent and intense sexual arousal from the act
of being humiliated, beaten, bound, or othenwise made to suffer, as manifested by fantasies, urges, or behaviors.
B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if:
With asphyxiophilia: If the individual engages in the practice of achieving sexual
arousal related to restriction of breathing.
Specify if:
In a controlled environment: This specifier is primarily applicable to individuals living
in institutional or other settings where opportunities to engage in masochistic sexual
behaviors are restricted.
In full remission: There has been no distress or impairment in social, occupational,
or other areas of functioning for at last 5 years while in an uncontrolled environment.
Diagnostic Features
The diagnostic criteria for sexual masochism disorder are intended to apply to individuals
who freely admit to having such paraphilic interests. Such individuals openly acknowledge intense sexual arousal from the act of being humiliated, beaten, bound, or otherwise
made to suffer, as manifested by fantasies, urges, or behaviors. If these individuals also report psychosocial difficulties because of their sexual attractions or preferences for being
humiliated, beaten, bound, or otherwise made to suffer, they may be diagnosed with sexual masochism disorder. In contrast, if they declare no distress, exemplified by anxiety, obsessions, guilt, or shame, about these paraphilic impulses, and are not hampered by them
in pursuing other personal goals, they could be ascertained as having masochistic sexual
interest but should not be diagnosed with sexual masochism disorder.
The Criterion A time frame, indicating that the signs or symptoms of sexual masochism must have persisted for at least 6 months, should be understood as a general guideline,
not a strict threshold, to ensure that the sexual interest in being humiliated, beaten, bound,
or otherwise made to suffer is not merely transient. However, the disorder can be diagnosed in the context of a clearly sustained but shorter time period.
Associated Features Supporting Diagnosis
The extensive use of pornography involving the act of being humiliated, beaten, bound, or otherwise made to suffer is sometimes an associated feature of sexual masochism disorder.
Prevaience
The population prevalence of sexual masochism disorder is unknown. In Australia, it has
been estimated that 2.2% of males and 1.3% of females had been involved in bondage and
discipline, sadomasochism, or dominance and submission in the past 12 months.
Development and Course
Community individuals with paraphilias have reported a mean age at onset for masochism of 19.3 years, although earlier ages, including puberty and childhood, have also been
reported for the onset of masochistic fantasies. Very little is known about persistence over
time. Sexual masochism disorder per definition requires one or more contributing factors,
which may change over time with or without treatment. These include subjective distress
(e.g., guilt, shame, intense sexual frustration, loneliness), psychiatric morbidity, hypersexuality and sexual impulsivity, and psychosocial impairment. Therefore, the course of sexual masochism disorder is likely to vary with age. Advancing age is likely to have the same
reducing effect on sexual preference involving sexual masochism as it has on other paraphilic or normophilic sexual behavior.
Functional Consequences of Sexual Masochism Disorder
The functional consequences of sexual masochism disorder are unknown. However, masochists are at risk of accidental death while practicing asphyxiophilia or other autoerotic
procedures.
Differential Diagnosis
Many of the conditions that could be differential diagnoses for sexual masochism disorder
(e.g., transvestic fetishism, sexual sadism disorder, hypersexuality, alcohol and substance
use disorders) sometimes occur also as comorbid diagnoses. Therefore, it is necessary to
carefully evaluate the evidence for sexual masochism disorder, keeping the possibility of
other paraphilias or other mental disorders as part of the differential diagnosis. Sexual
masochism in the absence of distress (i.e., no disorder) is also included in the differential,
as individuals who conduct the behaviors may be satisfied with their masochistic orientation.
Comorbidity
Known comorbidities with sexual masochism disorder are largely based on individuals in
treatment. Disorders that occur comorbidly with sexual masochism disorder typically include other paraphilic disorders, such as transvestic fetishism.
Sexual Sadism Disorder
Diagnostic Criteria 302.84 (F65.52)
A. Over a period of at least 6 months, recurrent and intense sexual arousal from the physical or psychological suffering of another person, as manifested by fantasies, urges, or
behaviors.
B. The individual has acted on these sexual urges with a nonconsenting person, or the
sexual urges or fantasies cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Specify if:
In a controlled environment: This specifier is primarily applicable to individuals living
in institutional or other settings where opportunities to engage in sadistic sexual behaviors are restricted.
In full remission: The individual has not acted on the urges with a nonconsenting person, and there has been no distress or impairment in social, occupational, or other areas of functioning, for at least 5 years while in an uncontrolled environment.
Diagnostic Features
The diagnostic criteria for sexual sadism disorder are intended to apply both to individuals
who freely admit to having such paraphilic interests and to those who deny any sexual interest
in the physical or psychological suffering of another individual despite substantial objective
evidence to the contrary. Individuals who openly acknowledge intense sexual interest in the
physical or psychological suffering of others are referred to as "admitting individuals." If these
individuals also report psychosocial difficulties because of their sexual attractions or preferences for the physical or psychological suffering of another individual, they may be diagnosed
with sexual sadism disorder. In contrast, if admitting individuals declare no distress, exemplified by anxiety, obsessions, guilt, or shame, about these paraphilic impulses, and are not hampered by them in pursuing other goals, and their self-reported, psychiatric, or legal histories
indicate that they do not act on them, then they could be ascertained as having sadistic sexual
interest but they would not meet criteria for sexual sadism disorder.
Examples of individuals who deny any interest in the physical or psychological suffering
of another individual include individuals known to have inflicted pain or suffering on multiple victims on separate occasions but who deny any urges or fantasies about such sexual
behavior and who may further claim that known episodes of sexual assault were either unintentional or nonsexual. Others may admit past episodes of sexual behavior involving the
infliction of pain or suffering on a nonconsenting individual but do not report any significant
or sustained sexual interest in the physical or psychological suffering of another individual.
Since these individuals deny having urges or fantasies involving sexual arousal to pain and
suffering, it follows that they would also deny feeling subjectively distressed or socially impaired by such impulses. Such individuals may be diagnosed with sexual sadism disorder
despite their negative self-report. Their recurrent behavior constitutes clinical support for
the presence of the paraphilia of sexual sadism (by satisfying Criterion A) and simultaneously demonstrates that their paraphilically motivated behavior is causing clinically significant distress, harm, or risk of harm to others (satisfying Criterion B).
"Recurrent" sexual sadism involving nonconsenting others (i.e., multiple victims, each
on a separate occasion) may, as general rule, be interpreted as three or more victims on
separate occasions. Fewer victims can be interpreted as satisfying this criterion, if there are
multiple instances of infliction of pain and suffering to the same victim, or if there is corroborating evidence of a strong or preferential interest in pain and suffering involving
multiple victims. Note that multiple victims, as suggested earlier, are a sufficient but not
a necessary condition for diagnosis, as the criteria may be met if the individual acknowledges intense sadistic sexual interest.
The Criterion A time frame, indicating that the signs or symptoms of sexual sadism
must have persisted for at least 6 months, should also be understood as a general guideline, not a strict threshold, to ensure that the sexual interest in inflicting pain and suffering
on nonconsenting victims is not merely transient. However, the diagnosis may be met if
there is a clearly sustained but shorter period of sadistic behaviors.
Associated Features Supporting Diagnosis
The extensive use of pornography involving the infliction of pain and suffering is sometimes an associated feature of sexual sadism disorder.
Prevalence
The population prevalence of sexual sadism disorder is unknown and is largely based on
individuals in forensic settings. Depending on the criteria for sexual sadism, prevalence
varies widely, from 2% to 30%. Among civilly committed sexual offenders in the United
States, less than 10% have sexual sadism. Among individuals who have committed sexually motivated homicides, rates of sexual sadism disorder range from 37% to 75%.
Development and Course
Individuals with sexual sadism in forensic samples are almost exclusively male, but a representative sample of the population in Australia reported that 2.2% of men and 1.3% of
women said they had been involved in bondage and discipline, "sadomasochism," or dominance and submission in the previous year. Information on the development and course
of sexual sadism disorder is extremely limited. One study reported that females became
aware of their sadomasochistic orientation as young adults, and another reported that the
mean age at onset of sadism in a group of males was 19.4 years. Whereas sexual sadism per
se is probably a lifelong characteristic, sexual sadism disorder may fluctuate according to
the individual's subjective distress or his or her propensity to harm nonconsenting others.
Advancing age is likely to have the same reducing effect on this disorder as it has on other
paraphilic or normophilic sexual behavior.
Differential Diagnosis
Many of the conditions that could be differential diagnoses for sexual sadism disorder
(e.g., antisocial personality disorder, sexual masochism disorder, hypersexuality, substance use disorders) sometimes occur also as comorbid diagnoses. Therefore, it is necessary to carefully evaluate the evidence for sexual sadism disorder, keeping the possibility
of other paraphilias or mental disorders as part of the differential diagnosis. The majority
of individuals who are active in community networks that practice sadistic and masochistic behaviors do not express any dissatisfaction with their sexual interests, and their behavior would not meet DSM-5 criteria for sexual sadism disorder. Sadistic interest, but not
the disorder, may be considered in the differential diagnosis.
Comorbidity
Known comorbidities with sexual sadism disorder are largely based on individuals (almost all males) convicted for criminal acts involving sadistic acts against nonconsenting
victims. Hence, these comorbidities might not apply to all individuals who never engaged
in sadistic activity with a nonconsenting victim but who qualify for a diagnosis of sexual
sadism disorder based on subjective distress over their sexual interest. Disorders that are
commonly comorbid with sexual sadism disorder include other paraphilic disorders.
Pedophilic Disorder
Diagnostic Criteria 302.2 (F65.4)
A. Over a period of at least 6 months, recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children
(generally age 13 years or younger).
B. The individual has acted on these sexual urges, or the sexual urges or fantasies cause
marked distress or interpersonal difficulty.
C. The individual is at least age 16 years and at least 5 years older than the child or children in Criterion A.
Note: Do not include an individual in late adolescence involved in an ongoing sexual
relationship with a 12- or 13-year-old.
Specify whether:
Exclusive type (attracted only to children)
Nonexclusive type
Specify if:
Sexually attracted to males
Sexually attracted to females
Sexually attracted to both
Specify if:
Limited to incest
Diagnostic Features
The diagnostic criteria for pedophilic disorder are intended to apply both to individuals who
freely disclose this paraphilia and to individuals who deny any sexual attraction to prepubertal children (generally age 13 years or younger), despite substantial objective evidence to the
contrary. Examples of disclosing this paraphilia include candidly acknowledging an intense
sexual interest in children and indicating that sexual interest in children is greater than or equal
to sexual interest in physically mature individuals. If individuals also complain that their sexual attractions or preferences for children are causing psychosocial difficulties, they may be diagnosed with pedophilic disorder. However, if they report an absence of feelings of guilt,
shame, or anxiety about these impulses and are not functionally limited by their paraphilic impulses (according to self-report, objective assessment, or both), and their self-reported and legally recorded histories indicate that they have never acted on their impulses, then these
individuals have a pedophilic sexual orientation but not pedophilic disorder.
Examples of individuals who deny attraction to children include individuals who are
known to have sexually approached multiple children on separate occasions but who deny
any urges or fantasies about sexual behavior involving children, and who may further claim
that the known episodes of physical contact were all unintentional and nonsexual. Other individuals may acknowledge past episodes of sexual behavior involving children but deny any
significant or sustained sexual interest in children. Since these individuals may deny experiences impulses or fantasies involving children, they may also deny feeling subjectively distressed. Such individuals may still be diagnosed with pedophilic disorder despite the absence
of self-reported distress, provided that there is evidence of recurrent behaviors persisting for
6 months (Criterion A) and evidence that the individual has acted on sexual urges or experienced interpersonal difficulties as a consequence of the disorder (Criterion B).
Presence of multiple victims, as discussed above, is sufficient but not necessary for diagnosis; that is, the individual can still meet Criterion A by merely acknowledging intense
or preferential sexual interest in children.
The Criterion A clause, indicating that the signs or symptoms of pedophilia have persisted for 6 months or longer, is intended to ensure that the sexual attraction to children is
not merely transient. However, the diagnosis may be made if there is clinical evidence of
sustained persistence of the sexual attraction to children even if the 6-month duration cannot be precisely determined.
Associated Features Supporting Diagnosis
The extensive use of pornography depicting prepubescent children is a useful diagnostic
indicator of pedophilic disorder. This is a specific instance of the general case that individuals are likely to choose the kind of pornography that corresponds to their sexual interests.
Prevalence
The population prevalence of pedophilic disorder is unknown. The highest possible prevalence for pedophilic disorder in the male population is approximately 3%-5%. The population prevalence of pedophilic disorder in females is even more uncertain, but it is likely
a small fraction of the prevalence in males.
Development and Course
Adult males \νιψ pedophilic disorder may indicate that they become aware of strong or
preferential sexual interest in children around the time of puberty—the same time frame
in which males who later prefer physically mature partners became aware of their sexual
interest in women or men. Attempting to diagnose pedophilic disorder at the age at which
it first manifests is problematic because of the difficulty during adolescent development in
differentiating it from age-appropriate sexual interest in peers or from sexual curiosity.
Hence, Criterion C requires for diagnosis a minimum age of 16 years and at least 5 years
older than the child or children in Criterion A.
Pedophilia per se appears to be a lifelong condition. Pedophilic disorder, however,
necessarily includes other elements that may change over time with or without treatment:
subjective distress (e.g., guilt, shame, intense sexual frustration, or feelings of isolation) or
psychosocial impairment, or the propensity to act out sexually with children, or both.
Therefore, the course of pedophilic disorder may fluctuate, increase, or decrease with age.
Adults with pedophilic disorder may report an awareness of sexual interest in children
that preceded engaging in sexual behavior involving children or self-identification as a pedophile. Advanced age is as likely to similarly diminish the frequency of sexual behavior involving children as it does other paraphilically motivated and normophilic sexual behavior.
Risk and Prognostic Factors
Temperamental. There appears to be an interaction between pedophilia and antisociality, such that males with both traits are more likely to act out sexually with children. Thus,
antisocial personality disorder may be considered a risk factor for pedophilic disorder in
males with pedophilia.
Environmental. Adult males with pedophilia often report that they were sexually abused
as children. It is unclear, however, whether this correlation reflects a causal influence of
childhood sexual abuse on adult pedophilia.
Genetic and physiological. Since pedophilia is a necessary condition for pedophilic disorder, any factor that increases the probability of pedophilia also increases the risk of pedophilic disorder. There is some evidence that neurodevelopmental perturbation in utero
increases the probability of development of a pedophilic orientation.
Gender-Related Diagnostic Issues
Psychophysiological laboratory measures of sexual interest, which are sometimes useful in diagnosing pedophilic disorder in males, are not necessarily useful in diagnosing this disorder in
females, even when an identical procedure (e.g., viewing time) or analogous procedures (e.g.,
penile plethysmography and vaginal photoplethysmography) are available.
Diagnostic IVIarkers
Psychophysiological measures of sexual interest may sometimes be useful when an individual's history suggests the possible presence of pedophilic disorder but the individual
denies strong or preferential attraction to children. The most thoroughly researched and
longest used of such measures is penile plethysmography, although the sensitivity and specificity of diagnosis may vary from one site to another. Viewing time, using photographs of
nude or minimally clothed persons as visual stimuli, is also used to diagnose pedophilic
disorder, especially in combination with self-report measures. Mental health professionals
in the United States, however, should be aware that possession of such visual stimuli, even
for diagnostic purposes, may violate American law regarding possession of child pornography and leave the mental health professional susceptible to criminal prosecution.
Differential Diagnosis
Many of the conditions that could be differential diagnoses for pedophilic disorder also
sometimes occur as comorbid diagnoses. It is therefore generally necessary to evaluate the
evidence for pedophilic disorder and other possible conditions as separate questions.
Antisocial personality disorder. This disorder increases the likelihood that a person who
is primarily attracted to the mature physique will approach a child, on one or a few occasions, on the basis of relative availability. The individual often shows other signs of this
personality disorder, such as recurrent law-breaking.
Alcohol and substance use disorders. The disinhibiting effects of intoxication may also
increase the likelihood that a person who is primarily attracted to the mature physique will
sexually approach a child.
Obsessive-compulsive disorder. There are occasional individuals who complain about
ego-dystonic thoughts and worries about possible attraction to children. Clinical interviewing usually reveals an absence of sexual thoughts about children during high states of
sexual arousal (e.g., approaching orgasm during masturbation) and sometimes additional
ego-dystonic, intrusive sexual ideas (e.g., concerns about homosexuality).
Comorbidity
Psychiatric comorbidity of pedophilic disorder includes substance use disorders; depressive, bipolar, and anxiety disorders; antisocial personality disorder; and other paraphilic
disorders. However, findings on comorbid disorders are largely among individuals convicted for sexual offenses involving children (almost all males) and may not be generalizable to other individuals with pedophilic disorder (e.g., individuals who have never
approached a child sexually but who qualify for the diagnosis of pedophilic disorder on
the basis of subjective distress).
Fetishistic Disorder
Diagnostic Criteria 302.81 (F65.0)
A. Over a period of at least 6 months, recurrent and intense sexual arousal from either
the use of nonliving objects or a highly specific focus on nongenital body part(s), as
manifested by fantasies, urges, or behaviors.
B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The fetish objects are not limited to articles of clothing used in cross-dressing (as in
transvestic disorder) or devices specifically designed for the puφose of tactile genital
stimulation (e.g., vibrator).
Specify:
Body part(s)
Nonliving object(s)
Other
Specify if:
in a controiied environment: This specifier is primarily applicable to individuals living
in institutional or other settings where opportunities to engage in fetishistic behaviors
are restricted.
in fuii remission: There has been no distress or impairment in social, occupational,
or other areas of functioning for at least 5 years while in an uncontrolled environment.
Specifiers
Although individuals with fetishistic disorder may report intense and recurrent sexual
arousal to inanimate objects or a specific body part, it is not unusual for non-mutually exclusive combinations of fetishes to occur. Thus, an individual may have fetishistic disorder
associated with an inanimate object (e.g., female undergarments) or an exclusive focus on
an intensely eroticized body part (e.g., feet, hair), or their fetishistic interest may meet criteria for various combinations of these specifiers (e.g., socks, shoes and feet).
Diagnostic Features
The paraphilic focus of fetishistic disorder involves the persistent and repetitive use of or dependence on nonliving objects or a highly specific focus on a (typically nongenital) body part
as primary elements associated with sexual arousal (Criterion A). A diagnosis of fetishistic disorder must include clinically significant personal distress or psychosocial role impairment
(Criterion B). Common fetish objects include female undergarments, male or female footwear,
rubber articles, leather clothing, or other wearing apparel. Highly eroticized body parts associated with fetishistic disorder include feet, toes, and hair. It is not uncommon for sexualized
fetishes to include both inanimate objects and body parts (e.g., dirty socks and feet), and for
this reason the definition of fetishistic disorder now re-incorporates partialism (i.e., an exclusive
focus on a body part) into its boundaries. Partialism, previously considered a paraphilia not
otherwise specified disorder, had historically been subsumed in fetishism prior to DSM-ΠΙ.
Many individuals who self-identify as fetishist practitioners do not necessarily report
clinical impairment in association with their fetish-associated behaviors. Such individuals
could be considered as having a fetish but not fetishistic disorder. A diagnosis of fetishistic
disorder requires concurrent fulfillment of both the behaviors in Criterion A and the clinically significant distress or impairment in functioning noted in Criterion B.
Associated Features Supporting Diagnosis
Fetishistic disorder can be a multisensory experience, including holding, tasting, rubbing,
inserting, or smelling the fetish object while masturbating, or preferring that a sexual partner wear or utilize a fetish object during sexual encounters. Some individuals may acquire
extensive collections of highly desired fetish objects.
Deveiopment and Course
Usually paraphilias have an onset during puberty, but fetishes can develop prior to adolescence. Once established, fetishistic disorder tends to have a continuous course that fluctuates in intensity and frequency of urges or behavior.
Cuiture-Reiated Diagnostic issues
Knowledge of and appropriate consideration for normative aspects of sexual behavior are
important factors to explore to establish a clinical diagnosis of fetishistic disorder and to
distinguish a clinical diagnosis from a socially acceptable sexual behavior.
Gender-Reiated Diagnostic issues
Fetishistic disorder has not been systematically reported to occur in females. In clinical
samples, fetishistic disorder is nearly exclusively reported in males.
Functionai Consequences of Fetishistic Disorder
Typical impairments associated with fetishistic disorder include sexual dysfunction
during romantic reciprocal relationships when the preferred fetish object or body part is
unavailable during foreplay or coitus. Some individuals with fetishistic disorder may prefer solitary sexual activity associated with their fetishistic preference(s) even while involved in a meaningful reciprocal and affectionate relationship.
Although fetishistic disorder is relatively uncommon among arrested sexual offenders
with paraphilias, males with fetishistic disorder may steal and collect their particular fetishistic objects of desire. Such individuals have been arrested and charged for nonsexual
antisocial behaviors (e.g., breaking and entering, theft, burglary) that are primarily motivated by the fetishistic disorder.
Differential Diagnosis
Transvestic disorder. The nearest diagnostic neighbor of fetishistic disorder is transvestic disorder. As noted in the diagnostic criteria, fetishistic disorder is not diagnosed when
fetish objects are limited to articles of clothing exclusively worn during cross-dressing (as
in transvestic disorder), or when the object is genitally stimulating because it has been designed for that purpose (e.g., a vibrator).
Sexual masochism disorder or other paraphilic disorders. Fetishes can co-occur with
other paraphilic disorders, especially "sadomasochism" and transvestic disorder. When
an individual fantasizes about or engages in "forced cross-dressing" and is primarily sexually aroused by the domination or humiliation associated with such fantasy or repetitive
activity, the diagnosis of sexual masochism disorder should be made.
Fetishistic behavior without fetishistic disorder. Use of a fetish object for sexual arousal
without any associated distress or psychosocial role impairment or other adverse consequence would not meet criteria for fetishistic disorder, as the threshold required by Criterion B would not be met. For example, an individual whose sexual partner either shares or
can successfully incorporate his interest in caressing, smelling, or licking feet or toes as an
important element of foreplay would not be diagnosed with fetishistic disorder; nor
would an individual who prefers, and is not distressed or impaired by, solitary sexual behavior associated with wearing rubber garments or leather boots.
Comorbidity
Fetishistic disorder may co-occur with other paraphilic disorders as well as hypersexuality. Rarely, fetishistic disorder may be associated with neurological conditions.
Transvestic Disorder
Diagnostic Criteria 302.3 (F65.1)
A. Over a period of at least 6 months, recurrent and intense sexual arousal from crossdressing, as manifested by fantasies, urges, or behaviors.
B. The fantasies, sexual urges, or behaviors cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if:
With fetishism: If sexually aroused by fabrics, materials, or garments.
With autogynephiiia: If sexually aroused by thoughts or images of self as female.
Specify if:
in a controiied environment: This specifier is primarily applicable to individuals living
in institutional or other settings where opportunities to cross-dress are restricted,
in fuii remission: There has been no distress or impairment in social, occupational,
or other areas of functioning for at least 5 years while in an uncontrolled environment.
Specifiers
The presence of fetishism decreases the likelihood of gender dysphoria in men with transvestic disorder. The presence of autogynephilia increases the likelihood of gender dysphoria in men with transvestic disorder.
Diagnostic Features
The diagnosis of transvestic disorder does not apply to all individuals who dress as the opposite sex, even those who do so habitually. It applies to individuals whose cross-dressing
or thoughts of cross-dressing are always or often accompanied by sexual excitement (Criterion A) and who are emotionally distressed by this pattern or feel it impairs social or interpersonal functioning (Criterion B). The cross-dressing may involve only one or two
articles of clothing (e.g., for men, it may pertain only to women's undergarments), or it
may involve dressing completely in the iimer and outer garments of the other sex and (in
men) may include the use of women's wigs and make-up. Transvestic disorder is nearly
exclusively reported in males. Sexual arousal, in its most obvious form of penile erection,
may co-occur with cross-dressing in various ways. In younger males, cross-dressing often
leads to masturbation, following which any female clothing is removed. Older males often
leam to avoid masturbating or doing anything to stimulate the penis so that the avoidance
of ejaculation allows them to prolong their cross-dressing session. Males with female partners sometimes complete a cross-dressing session by having intercourse with their partners, and some have difficulty maintaining a sufficient erection for intercourse without
cross-dressing (or private fantasies of cross-dressing).
Clinical assessment of distress or impairment, like clinical assessment of transvestic
sexual arousal, is usually dependent on the individual's self-report. The pattern of behavior "purging and acquisition" often signifies the presence of distress in individuals with
transvestic disorder. During this behavioral pattern, an individual (usually a man) who
has spent a great deal of money on women's clothes and other apparel (e.g., shoes, wigs)
discards the items (i.e., purges them) in an effort to overcome urges to cross-dress, and
then begins acquiring a woman's wardrobe all over again.
Associated Features Supporting Diagnosis
Transvestic disorder in men is often accompanied by autogynephilia (i.e., a male's paraphilic tendency to be sexually aroused by the thought or image of himself as a woman).
Autogynephilic fantasies and behaviors may focus on the idea of exhibiting female physiological functions (e.g., lactation, menstruation), engaging in stereotypically feminine behavior (e.g., knitting), or possessing female anatomy (e.g., breasts).
Prevaience
The prevalence of transvestic disorder is unknown. Transvestic disorder is rare in males
and extremely rare in females. Fewer than 3% of males report having ever been sexually
aroused by dressing in women's attire. The percentage of individuals who have crossdressed with sexual arousal more than once or a few times in their lifetimes would be even
lower. The majority of males with transvestic disorder identify as heterosexual, although
some individuals have occasional sexual interaction with other males, especially when
they are cross-dressed.
Deveiopment and Course
In males, the first signs of transvestic disorder may begin in childhood, in the form of
strong fascination with a particular item of women's attire. Prior to puberty, cross-dressing produces generalized feelings of pleasurable excitement. With the arrival of puberty,
dressing in women's clothes begins to elicit penile erection and, in some cases, leads di
rectly to first ejaculation. In many cases, cross-dressing elicits less and less sexual excitement as the individual grows older; eventually it may produce no discernible penile
response at all. The desire to cross-dress, at the same time, remains the same or grows even
stronger. Individuals who report such a diminution of sexual response typically report
that the sexual excitement of cross-dressing has been replaced by feelings of comfort or
well-being.
In some cases, the course of transvestic disorder is continuous, and in others it is episodic. It is not rare for men with transvestic disorder to lose interest in cross-dressing when
they first fall in love with a woman and begin a relationship, but such abatement usually
proves temporary. When the desire to cross-dress returns, so does the associated distress.
Some cases of transvestic disorder progress to gender dysphoria. The males in these
cases, who may be indistinguishable from others with transvestic disorder in adolescence
or early childhood, gradually develop desires to remain in the female role for longer periods and to feminize their anatomy. The development of gender dysphoria is usually accompanied by a (self-reported) reduction or elimination of sexual arousal in association
with cross-dressing.
The manifestation of transvestism in penile erection and stimulation, like the manifestation of other paraphilic as well as normophiHc sexual interests, is most intense in adolescence
and early adulthood. The severity of transvestic disorder is highest in adulthood, when the
transvestic drives are most likely to conflict with performance in heterosexual intercourse
and desires to marry and start a family. Middle-age and older men with a history of transvestism are less likely to present with transvestic disorder than with gender dysphoria.
Functional Consequences of Transvestic Disorder
Engaging in transvestic behaviors can interfere with, or detract from, heterosexual relationships. This can be a source of distress to men who wish to maintain conventional marriages or romantic partnerships with women.
Differentiai Diagnosis
Fetishistic disorder. This disorder may resemble transvestic disorder, in particular, in
men with fetishism who put on women's undergarments while masturbating with them.
Distinguishing transvestic disorder depends on the individual's specific thoughts during
such activity (e.g., are there any ideas of being a woman, being like a woman, or being
dressed as a woman?) and on the presence of other fetishes (e.g., soft, silky fabrics, whether
these are used for garments or for something else).
Gender dysphoria. Individuals with transvestic disorder do not report an incongruence between their experienced gender and assigned gender nor a desire to be of the other gender; and
they typically do not have a history of childhood cross-gender behaviors, which would be
present in individuals with gender dysphoria. Individuals with a presentation that meets fuU
criteria for transvestic disorder as weU as gender dysphoria should be given both diagnoses.
Comorbidity
Transvestism (and thus transvestic disorder) is often found in association with other paraphilias. The most frequently co-occurring paraphilias are fetishism and masochism. One
particularly dangerous form of masochism, autoerotic asphyxia, is associated with transvestism in a substantial proportion of fatal cases.
Other Specified Paraphilic Disorder
302.89 (F65.89)
This category applies to presentations in which symptoms characteristic of a paraphilic 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 paraphilic disorders diagnostic class. The other specified paraphilic disorder category is
used in situations in which the clinician chooses to communicate the specific reason that the
presentation does not meet the criteria for any specific paraphilic disorder. This is done by recording “other specified paraphilic disorder'’ followed by the specific reason (e.g., “zoophilia”).
Examples of presentations that can be specified using the “other specified” designation
include, but are not limited to, recurrent and intense sexual arousal involving telephone
scatologia (obscene phone calls), necrophilia (coφses), zoophilia (animals), coprophilia
(feces), klismaphilia (enemas), or urophilia (urine) that has been present for at least 6 months
and causes marked distress or impairment in social, occupational, or other important areas of functioning. Other specified paraphilic disorder can be specified as in remission
and/or as occurring in a controlled environment.
Unspecified Paraphilic Disorder
302.9 (F65.9)
This category applies to presentations in which symptoms characteristic of a paraphilic
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 paraphilic disorders diagnostic class. The unspecified paraphilic disorder category is used in situations in which the clinician chooses not to specify the reason
that the criteria are not met for a specific paraphilic disorder, and includes presentations
in which there is insufficient information to make a more specific diagnosis.
F o u r d iSO rd G fS are included in this chapter: other specified mental disorder due to
another medical condition; unspecified mental disorder due to another medical condition;
other specified mental disorder; and unspecified mental disorder. This residual category
applies to presentations in which symptoms characteristic of a mental 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 other mental disorder in DSM-5. For other specified and unspecified mental disorders due to another
medical condition, it must be established that the disturbance is caused by the physiological effects of another medical condition. If other specified and unspecified mental disorders are due to another medical condition, it is necessary to code and list the medical
condition first (e.g., 042 [B20] HIV disease), followed by the other specified or unspecified
mental disorder (use appropriate code).
Other Specified IVIental Disorder
Due to Another l\/ledical Condition
This category applies to presentations in which symptoms characteristic of a mental disorder due to another medical condition 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 specific mental disorder attributable to another medical
condition. The other specified mental disorder due to another medical condition category
is used in situations in which the clinician chooses to communicate the specific reason that
the presentation does not meet the criteria for any specific mental disorder attributable to
another medical condition. This is done by recording the name of the disorder, with the
specific etiological medical condition inserted in place of “another medical condition,” followed by the specific symptomatic manifestation that does not meet the criteria for any
specific mental disorder due to another medical condition. Furthermore, the diagnostic
code for the specific medical condition must be listed immediately before the code for the
other specified mental disorder due to another medical condition. For example, dissociative symptoms due to complex partial seizures would be coded and recorded as 345.40
(G40.209), complex partial seizures 294.8 (F06.8) other specified mental disorder due to
complex partial seizures, dissociative symptoms.
An example of a presentation that can be specified using the “other specified” designation is the following:
Dissociative symptoms: This includes symptoms occurring, for example, in the context of complex partial seizures.
Unspecified IVIental Disorder
Due to Another IVIedical Condition
294.9 (F09)
This category applies to presentations in which symptoms characteristic of a mental disorder due to another medical condition 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 specific mental disorder due to another medical condition.
The unspecified mental disorder due to another medical condition category is used in situations in which the clinician chooses nof to specify the reason that the criteria are not met
for a specific mental disorder due to another medical condition, and includes presentations
for which there is insufficient information to make a more specific diagnosis (e.g., in emergency room settings). This is done by recording the name of the disorder, with the specific
etiological medical condition inserted in place of “another medical condition.” Furthermore,
the diagnostic code for the specific medical condition must be listed immediately before
the code for the unspecified mental disorder due to another medical condition. For example, dissociative symptoms due to complex partial seizures would be coded and recorded
as 345.40 (G40.209) complex partial seizures, 294.9 (F06.9) unspecified mental disorder
due to complex partial seizures.
Other Specified Mental Disorder
300.9 (F99)
This category applies to presentations in which symptoms characteristic of a mental 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
specific mental disorder. The other specified mental disorder category is used in situations
in which the clinician chooses to communicate the specific reason that the presentation
does not meet the criteria for any specific mental disorder. This is done by recording “other
specified mental disorder” followed by the specific reason.
Unspecified Mental Disorder
300.9 (F99)
This category applies to presentations in which symptoms characteristic of a mental 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
mental disorder. The unspecified mental disorder category is used in situations in which
the clinician chooses not to specify the reason that the criteria are not met for a specific
mental disorder, and includes presentations for which there is insufficient information to
make a more specific diagnosis (e.g., in emergency room settings).
Medication-Induced Movement
Disorders and Otiier Adverse
Effects of Medication
MGCliCâtiOn-indUCGCl movement disorders are included in Section II because of
their frequent importance in 1) the management by medication of mental disorders or other medical conditions and 2) the differential diagnosis of mental disorders (e.g., anxiety
disorder versus neuroleptic-induced akathisia; malignant catatonia versus neuroleptic
malignant syndrome). Although these movement disorders are labeled "medication induced," it is often difficult to establish the causal relationship between medication exposure and the development of the movement disorder, especially because some of these
movement disorders also occur in the absence of medication exposure. The conditions
and problems listed in this chapter are not mental disorders.
The term neuroleptic is becoming outdated because it highlights the propensity of antipsychotic medications to cause abnormal movements, and it is being replaced with the
term antipsychotic in many contexts. Nevertheless, the term neuroleptic remains appropriate in this context. Although newer antipsychotic medications may be less likely to cause
some medication-induced movement disorders, those disorders still occur. Neuroleptic
medications include so-called conventional, "typical," or first-generation antipsychotic
agents (e.g., chlorpromazine, haloperidol, fluphenazine); "atypical" or second-generation
antipsychotic agents (e.g., clozapine, risperidone, olanzapine, quetiapine); certain dopamine receptor-blocking drugs used in the treatment of symptoms such as nausea and gastroparesis (e.g., prochlorperazine, promethazine, trimethobenzamide, thiethylperazine,
metoclopramide); and amoxapine, which is marketed as an antidepressant.
Neuroleptic-Induced Parkinsonism
Other Medication-Induced Parkinsonism
332.1 (G21.11 ) Neuroleptic-Induced Parkinsonism
332.1 (G21.19) Other Medication-Induced Parkinsonism
Parkinsonian tremor, muscular rigidity, akinesia (i.e., loss of movement or difficulty initiating movement), or bradykinesia (i.e., slowing movement) developing within a few
weeks of starting or raising the dosage of a medication (e.g., a neuroleptic) or after reducing the dosage of a medication used to treat extrapyramidal symptoms.
Neuroleptic Malignant Syndrome
333.92 (G21.0) Neuroleptic Malignant Syndrome
Although neuroleptic malignant syndrome is easily recognized in its classic full-blown
form, it is often heterogeneous in onset, presentation, progression, and outcome. The clinical features described below are those considered most important in making the diagnosis of neuroleptic malignant syndrome based on consensus recommendations.
Diagnostic Features
Patients have generally been exposed to a dopamine antagonist within 72 hours prior to
symptom development. Hyperthermia (>100.4°F or >38.0°C on at least two occasions,
measured orally), associated with profuse diaphoresis, is a distinguishing feature of neuroleptic malignant syndrome, setting it apart from other neurological side effects of antipsychotic medications. Extreme elevations in temperature, reflecting a breakdown in
central thermoregulation, are more likely to support the diagnosis of neuroleptic malignant syndrome. Generalized rigidity, described as "lead pipe" in its most severe form and
usually unresponsive to antiparkinsonian agents, is a cardinal feature of the disorder and
may be associated with other neurological symptoms (e.g., tremor, sialorrhea, akinesia,
dystonia, trismus, myoclonus, dysarthria, dysphagia, rhabdomyolysis). Creatine kinase
elevation of at least four times the upper limit of normal is commonly seen. Changes in
mental status, characterized by delirium or altered consciousness ranging from stupor to
coma, are often an early sign. Affected individuals may appear alert but dazed and unresponsive, consistent with catatonic stupor. Autonomic activation and instability—manifested by tachycardia (rate >25% above baseline), diaphoresis, blood pressure elevation
(systolic or diastolic >25% above baseline) or fluctuation (>20 mmHg diastolic change or
>25 mmHg systolic change within 24 hours), urinary incontinence, and pallor—may be
seen at any time but provide an early clue to the diagnosis. Tachypnea (rate >50% above
baseline) is common, and respiratory distress—resulting from metabolic acidosis, hypermetabolism, chest wall restriction, aspiration pneumonia, or pulmonary emboli—can occur and lead to sudden respiratory arrest.
A workup, including laboratory investigation, to exclude other infectious, toxic, metabolic, and neuropsychiatric etiologies or complications is essential (see the section "Differential Diagnosis" later in this discussion). Although several laboratory abnormalities
are associated with neuroleptic malignant syndrome, no single abnormality is specific to
the diagnosis. Individuals with neuroleptic malignant syndrome may have leukocytosis,
metabolic acidosis, hypoxia, decreased serum iron concentrations, and elevations in serum muscle enzymes and catecholamines. Findings from cerebrospinal fluid analysis and
neuroimaging studies are generally normal, whereas electroencephalography shows generalized slowing. Autopsy findings in fatal cases have been nonspecific and variable, depending on complications.
Development and Course
Evidence from database studies suggests incidence rates for neuroleptic malignant syndrome of 0.01%-0.02% among individuals treated with antipsycho tics. The temporal progression of signs and symptoms provides important clues to the diagnosis and prognosis
of neuroleptic malignant syndrome. Alteration in mental status and other neurological
signs typically precede systemic signs. The onset of symptoms varies from hours to days
after drug initiation. Some cases develop within 24 hours after drug initiation, most within
the first week, and virtually all cases within 30 days. Once the syndrome is diagnosed and
oral antipsychotic drugs are discontinued, neuroleptic malignant syndrome is self-limited
in most cases. The mean recovery time after drug discontinuation is 7-10 days, with most
individuals recovering within 1 week and nearly all within 30 days. The duration may be
prolonged when long-acting antipsychotics are implicated. There have been reports of individuals in whom residual neurological signs persisted for weeks after the acute hypermetabolic symptoms resolved. Total resolution of symptoms can be obtained in most
cases of neuroleptic malignant syndrome; however, fatality rates of 10%-20% have been
reported when the disorder is not recognized. Although many individuals do not experience a recurrence of neuroleptic malignant syndrome when rechallenged with antipsychotic medication, some do, especially when antipsychotics are reinstituted soon after an
episode.
Risk and Prognostic Factors
Neuroleptic malignant syndrome is a potential risk in any individual after antipsychotic
drug administration. It is not specific to any neuropsychiatric diagnosis and may occur in
individuals without a diagnosable mental disorder who receive dopamine antagonists.
Clinical, systemic, and metabolic factors associated with a heightened risk of neuroleptic
malignant syndrome include agitation, exhaustion, dehydration, and iron deficiency. A
prior episode associated with antipsychotics has been described in 15%-20% of index
cases, suggesting underlying vulnerability in some patients; however, genetic findings
based on neurotransmitter receptor polymorphisms have not been replicated consistently.
Nearly all dopamine antagonists have been associated with neuroleptic malignant
sjmdrome, although high-potency antipsychotics pose a greater risk compared with lowpotency agents and newer atypical antipsychotics. Partial or milder forms may be associated with newer antipsychotics, but neuroleptic malignant syndrome varies in severity
even with older drugs. Dopamine antagonists used in medical settings (e.g., metoclopramide, prochlorperazine) have also been implicated. Parenteral administration routes,
rapid titration rates, and higher total drug dosages have been associated with increased
risk; however, neuroleptic malignant syndrome usually occurs within the therapeutic dosage range of antipsychotics.
Differential Diagnosis
Neuroleptic malignant syndrome must be distinguished from other serious neurological
or medical conditions, including central nervous system infections, inflammatory or autoimmune conditions, status epilepticus, subcortical structural lesions, and systemic conditions (e.g., pheochromocytoma, thyrotoxicosis, tetanus, heat stroke).
Neuroleptic malignant syndrome also must be distinguished from similar syndromes
resulting from the use of other substances or medications, such as serotonin syndrome;
parkinsonian hyperthermia syndrome following abrupt discontinuation of dopamine agonists; alcohol or sedative withdrawal; malignant hyperthermia occurring during anesthesia; hyperthermia associated with abuse of stimulants and hallucinogens; and atropine
poisoning from anticholinergics.
In rare instances, individuals with schizophrenia or a mood disorder may present with
malignant catatonia, which may be indistinguishable from neuroleptic malignant syndrome. Some investigators consider neuroleptic malignant syndrome to be a druginduced form of malignant catatonia.
Medication-Induced Acute Dystonia
333.72 (G24.02) Medication-Induced Acute Dystonia
Abnormal and prolonged contraction of the muscles of the eyes (oculogyric crisis), head,
neck (torticollis or retrocollis), limbs, or trunk developing within a few days of starting or
raising the dosage of a medication (such as a neuroleptic) or after reducing the dosage of a
medication used to treat extrapyramidal symptoms.
IVledication-lnduced Acute Al<atlnisia
333.99 (G25.71) Medication-Induced Acute Akathisia
Subjective complaints of restlessness, often accompanied by observed excessive movements (e.g., fidgety movements of the legs, rocking from foot to foot, pacing, inability to sit
or stand still), developing within a few weeks of starting or raising the dosage of a medication (such as a neuroleptic) or after reducing the dosage of a medication used to treat extrapyramidal symptoms.
Tardive Dyskinesia
333.85 (G24.01) Tardive Dyskinesia
Involuntary athetoid or choreiform movements (lasting at least a few weeks) generally of
the tongue, lower face and jaw, and extremities (but sometimes involving the pharyngeal,
diaphragmatic, or trunk muscles) developing in association with the use of a neuroleptic
medication for at least a few months.
Symptoms may develop after a shorter period of medication use in older persons. In
some patients, movements of this type may appear after discontinuation, or after change
or reduction in dosage, of neuroleptic medications, in which case the condition is called
neuroleptic withdrawal-emergent dyskinesia. Because withdrawal-emergent dyskinesia is
usually time-limited, lasting less than 4-8 weeks, dyskinesia that persists beyond this window is considered to be tardive dyskinesia.
Tardive Dystonia
Tardive Akathisia
333.72 (G24.09) Tardive Dystonia
333.99 (G25.71 ) Tardive Akathisia
Tardive syndrome involving other types of movement problems, such as dystonia or
akathisia, which are distinguished by their late emergence in the course of treatment and
their potential persistence for months to years, even in the face of neuroleptic discontinuation or dosage reduction.
Medication-Induced Postural Tremor
333.1 (G25.1) Medication-Induced Postural Tremor
Fine tremor (usually in the range of 8-12 Hz) occurring during attempts to maintain a posture and developing in association with the use of medication (e.g., lithium, antidepressants, valproate). This tremor is very similar to the tremor seen with anxiety, caffeine, and
other stimulants.
Other Medication-Induced Movement Disorder
333.99 (G25.79) Other Medication-Induced Movement Disorder
This category is for medication-induced movement disorders not captured by any of the
specific disorders listed above. Examples include 1) presentations resembling neuroleptic
malignant syndrome that are associated with medications other than neuroleptics and
2) other medication-induced tardive conditions.
Antidepressant Discontinuation Syndrome
995.29 (T43.205A) Initial encounter
995.29 (T43.205D) Subsequent encounter
995.29 (T43.205S) Sequelae
Antidepressant discontinuation syndrome is a set of symptoms that can occur after an
abrupt cessation (or marked reduction in dose) of an antidepressant medication that was
taken continuously for at least 1 month. Symptoms generally begin within 2-4 days and
typically include specific sensory, somatic, and cognitive-emotional manifestations. Fre
quently reported sensory and somatic symptoms include flashes of lights, "electric shock"
sensations, nausea, and hyperresponsivity to noises or lights. Nonspecific anxiety and
feelings of dread may also be reported. Symptoms are alleviated by restarting the same
medication or starting a different medication that has a similar mechanism of action—
for example, discontinuation symptoms after withdrawal from a serotonin-norepinephrine reuptake inhibitor may be alleviated by starting a tricyclic antidepressant. To qualify
as antidepressant discontinuation syndrome, the symptoms should not have been present
before the antidepressant dosage was reduced and are not better explained by another
mental disorder (e.g., manic or hypomanie episode, substance intoxication, substance
withdrawal, somatic symptom disorder).
Diagnostic Features
Discontinuation symptoms may occur following treatment with tricyclic antidepressants
(e.g., imipramine, amitriptyline, desipramine), serotonin reuptake inhibitors (e.g., fluoxetine, paroxetine, sertraline), and monoamine oxidase inhibitors (e.g., phenelzine, selegiline, pargyline). The incidence of this syndrome depends on the dosage and half-life of the
medication being taken, as well as the rate at which the medication is tapered. Short-acting
medications that are stopped abruptly rather than tapered gradually may pose the greatest risk. The short-acting selective serotonin reuptake inhibitor (SSRI) paroxetine is the
agent most commonly associated with discontinuation symptoms, but such symptoms occur for all types of antidepressants.
Unlike withdrawal syndromes associated with opioids, alcohol, and other substances
of abuse, antidepressant discontinuation syndrome has no pathognomonic symptoms. Instead, the symptoms tend to be vague and variable and typically begin 2-A days after the
last dose of the antidepressant. For SSRIs (e.g., paroxetine), symptoms such as dizziness,
ringing in the ears, "electric shocks in the head," an inability to sleep, and acute anxiety are
described. The antidepressant use prior to discontinuation must not have incurred hypomania or euphoria (i.e., there should be confidence that the discontinuation syndrome is
not the result of fluctuations in mood stability associated with the previous treatment).
The antidepressant discontinuation syndrome is based solely on pharmacological factors
and is not related to the reinforcing effects of an antidepressant. Also, in the case of stimulant augmentation of an antidepressant, abrupt cessation may result in stimulant withdrawal symptoms (see "Stimulant Withdrawal" in the chapter "Substance-Related and
Addictive Disorders") rather than the antidepressant discontinuation syndrome described
here.
Prevalence
The prevalence of antidepressant discontinuation syndrome is unknown but is thought to
vary according to the dosage prior to discontinuation, the half-life and receptor-binding
affinity of the medication, and possibly the individual's genetically influenced rate of metabolism for this medication.
Course and Development
Because longitudinal studies are lacking, litfle is known about the clinical course of antidepressant discontinuation syndrome. Symptoms appear to abate over time with very
gradual dosage reductions. After an episode, some individuals may prefer to resume medication indefinitely if tolerated.
Differential Diagnosis
The differential diagnosis of antidepressant discontinuation syndrome includes anxiety
and depressive disorders, substance use disorders, and tolerance to medications.
Anxiety and depressive disorders. Discontinuation symptoms often resemble symptoms
of a persistent anxiety disorder or a return of somatic symptoms of depression for which
the medication was initially given.
Substance use disorders. Antidepressant discontinuation syndrome differs from substance withdrawal in that antidepressants themselves have no reinforcing or euphoric effects. The medication dosage has usually not been increased without the clinician's
permission, and the individual generally does not engage in drug-seeking behavior to obtain additional medication. Criteria for a substance use disorder are not met.
Tolerance to medications. Tolerance and discontinuation symptoms can occur as a
normal physiological response to stopping medication after a substantial duration of
exposure. Most cases of medication tolerance can be managed through carefully controlled tapering.
Comorbidity
Typically, the individual was initially started on the medication for a major depressive disorder; the original symptoms may return during the discontinuation syndrome.
Other Adverse Effect of Medication
995.20 (T50.905A) Initial encounter
995.20 (T50.905D) Subsequent encounter
995.20 (T50.905S) Sequelae
This category is available for optional use by clinicians to code side effects of medication
(other than movement symptoms) when these adverse effects become a main focus of clinical attention. Examples include severe hypotension, cardiac arrhythmias, and priapism.
other Conditions That May Be
a Focus of Ciinicai Attention
T h is d is c u s s io n covers other conditions and problems that may be a focus of clinical attention or that may otherwise affect the diagnosis, course, prognosis, or treatment of
a patient's mental disorder. These conditions are presented with their corresponding
codes from ICD-9-CM (usually V codes) and ICD-IO-CM (usually Z codes). A condition
or problem in this chapter may be coded if it is a reason for the current visit or helps to
explain the need for a test, procedure, or treatment. Conditions and problems in this chapter may also be included in the medical record as useful information on circumstances that
may affect the patient's care, regardless of their relevance to the current visit.
The conditions and problems listed in this chapter are not mental disorders. Their inclusion in DSM-5 is meant to draw attention to the scope of additional issues that may be
encountered in routine clinical practice and to provide a systematic listing that may be
useful to clinicians in documenting these issues.
Relational Problems
Key relationships, especially intimate adult partner relationships and parent/caregiverchild relationships, have a significant impact on the health of the individuals in these relationships. These relationships can be health promoting and protective, neutral, or detrimental to health outcomes. In the extreme, these close relationships can be associated with
maltreatment or neglect, which has significant medical and psychological consequences
for the affected individual. A relational problem may come to clinical attention either as
the reason that the individual seeks health care or as a problem that affects the course,
prognosis, or treatment of the individual's mental or other medical disorder.
Problems Related to Family Upbringing
V61.20 (Z62.820) Parent-Child Relational Problem
For this category, the term parent is used to refer to one of the child's primary caregivers,
who may be a biological, adoptive, or foster parent or may be another relative (such as a
grandparent) who fulfills a parental role for the child. This category should be used when
the main focus of clinical attention is to address the quality of the parent-child relationship
or when the quality of the parent-child relationship is affecting the course, prognosis, or
treatment of a mental or other medical disorder. Typically, the parent-child relational
problem is associated with impaired functioning in behavioral, cognitive, or affective domains. Examples of behavioral problems include inadequate parental control, supervision,
and involvement with the child; parental overprotection; excessive parental pressure; arguments that escalate to threats of physical violence; and avoidance without resolution of
problems. Cognitive problems may include negative attributions of the other's intentions,
hostility toward or scapegoating of the other, and unwarranted feelings of estrangement.
Affective problems may include feelings of sadness, apathy, or anger about the other individual in the relationship. Clinicians should take into account the developmental needs
of the child and the cultural context.
V61.8 (Z62.891 ) Sibling Relational Problem
This category should be used when the focus of clinical attention is a pattern of interaction
among siblings that is associated with significant impairment in individual or family functioning or with development of symptoms in one or more of the siblings, or when a sibling relational
problem is affecting the course, prognosis, or treatment of a sibling's mental or other medical
disorder. This category can be used for either children or adults if the focus is on the sibling relationship. Siblings in this context include full, half-, step-, foster, and adopted siblings.
V61.8 (Z62.29) Upbringing Away From Parents
This category should be used when the main focus of clinical attention pertains to issues
regarding a child being raised away from the parents or when this separate upbringing affects the course, prognosis, or treatment of a mental or other medical disorder. The child
could be one who is under state custody and placed in kin care or foster care. The child
could also be one who is living in a nonparental relative's home, or with friends, but whose
out-of-home placement is not mandated or sanctioned by the courts. Problems related to a
child living in a group home or orphanage are also included. This category excludes issues
related to V60.6 (Z59.3) children in boarding schools.
V61.29 (Z62.898) Child Affected by Parental Relationship Distress
This category should be used when the focus of clinical attention is the negative effects of
parental relationship discord (e.g., high levels of conflict, distress, or disparagement) on a
child in the family, including effects on the child's mental or other medical disorders.
other Problems Related to Primary Support Group
V61.10 (Z63.0) Relationship Distress With Spouse or Intimate Partner
This category should be used when the major focus of the clinical contact is to address the
quality of the intimate (spouse or partner) relationship or when the quality of that relationship is affecting the course, prognosis, or treatment of a mental or other medical disorder. Partners can be of the same or different genders. Typically, the relationship distress
is associated with impaired functioning in behavioral, cognitive, or affective domains. Examples of behavioral problems include conflict resolution difficulty, withdrawal, and
overinvolvement. Cognitive problems can manifest as chronic negative attributions of the
other's intentions or dismissals of the partner's positive behaviors. Affective problems
would include chronic sadness, apathy, and/or anger about the other partner.
Note: This category excludes clinical encounters for V61.1x (Z69.1x) mental health services for spousal or partner abuse problems and V65.49 (Z70.9) sex counseling.
V61.03 (Z63.5) Disruption of Family by Separation or Divorce
This category should be used when partners in an intimate adult couple are living apart
due to relationship problems or are in the process of divorce.
V61.8 (Z63.8) High Expressed Emotion Level Within Family
Expressed emotion is a construct used as a qualitative measure of the "amount" of emotion—in particular, hostility, emotional overinvolvement, and criticism directed toward a
family member who is an identified patient—displayed in the family environment. This
category should be used when a family's high level of expressed emotion is the focus of
clinical attention or is affecting the course, prognosis, or treatment of a family member's
mental or other medical disorder.
V62.82 (Z63.4) Uncomplicated Bereavement
This category can be used when the focus of clinical attention is a normal reaction to the
death of a loved one. As part of their reaction to such a loss, some grieving individuals
present with symptoms characteristic of a major depressive episode—for example, feel
ings of sadness and associated symptoms such as insomnia, poor appetite, and weight
loss. The berea>(ed individual typically regards the depressed mood as "normal," although the individual may seek professional help for relief of associated symptoms such
as insomnia or anorexia. The duration and expression of "normal" bereavement vary considerably among different cultural groups. Further guidance in distinguishing grief from
a major depressive episode is provided in the criteria for major depressive episode.
Abuse and Neglect
Maltreatment by a family member (e.g., caregiver, intimate adult partner) or by a nonrelative can be the area of current clinical focus, or such maltreatment can be an important
factor in the assessment and treatment of patients with mental or other medical disorders.
Because of the legal implications of abuse and neglect, care should be used in assessing
these conditions and assigning these codes. Having a past history of abuse or neglect can
influence diagnosis and treatment response in a number of mental disorders, and may also
be noted along with the diagnosis.
For the following categories, in addition to listings of the confirmed or suspected event
of abuse or neglect, other codes are provided for use if the current clinical encounter is to
provide mental health services to either the victim or the perpetrator of the abuse or neglect. A separate code is also provided for designating a past history of abuse or neglect.
Coding Note for ICD-IO-CM Abuse and Neglect Conditions
For T codes only, the 7th character should be coded as follows:
A (initial encounter)—Use while the patient is receiving active treatment for
the condition (e.g., surgical treatment, emergency department encounter, evaluation and treatment by a new clinician); or
D (subsequent encounter)—Use for encounters after the patient has received
active treatment for the condition and when he or she is receiving routine care
for the condition during the healing or recovery phase (e.g., cast change or removal, removal of external or internal fixation device, medication adjustment,
other aftercare and follow-up visits).
Child Maltreatm ent and Neglect Problems
Child Physical Abuse
Child physical abuse is nonaccidental physical injury to a child—^ranging from minor bruises
to severe fractures or death—occurring as a result of punching, beating, kicking, biting,
shaking, throwing, stabbing, choking, hitting (with a hand, stick, strap, or other object),
burning, or any other method that is inflicted by a parent, caregiver, or other individual who
has responsibility for the child. Such injury is considered abuse regardless of whether the
caregiver intended to hurt the child. Physical discipline, such as spanking or paddling, is not
considered abuse as long as it is reasonable and causes no bodily injury to the child.
Child Physical Abuse, Confirmed
995.54 (T74.12XA) Initial encounter
995.54 (T74.12XD) Subsequent encounter
Child Physical Abuse, Suspected
995.54 (T76.12XA) Initial encounter
995.54 (T76.12XD) Subsequent encounter
Other Circumstances Related to Child Physical Abuse
V61.21 (Z69.010) Encounter for mental health services for victim of child abuse by parent
V61.21 (Z69.020) Encounter for mental health services for victim of nonparental child
abuse
VI 5.41 (Z62.810) Personal history (past history) of physical abuse in childhood
V61.22 (Z69.011 ) Encounter for mental health services for perpetrator of parental child
abuse
V62.83 (Z69.021) Encounter for mental health services for perpetrator of nonparental
child abuse
Child Sexual Abuse
Child sexual abuse encompasses any sexual act involving a child that is intended to provide sexual gratification to a parent, caregiver, or other individual who has responsibility
for the child. Sexual abuse includes activities such as fondling a child's genitals, penetration, incest, rape, sodomy, and indecent exposure. Sexual abuse also includes noncontact
exploitation of a child by a parent or caregiver—for example, forcing, tricking, enticing,
threatening, or pressuring a child to participate in acts for the sexual gratification of others,
without direct physical contact between child and abuser.
Child Sexual Abuse, Confirmed
995.53 (T74.22XA) Initial encounter
995.53 (T74.22XD) Subsequent encounter
Child Sexual Abuse, Suspected
995.53 (T76.22XA) Initial encounter
995.53 (T76.22XD) Subsequent encounter
Other Circumstances Related to Child Sexual Abuse
V61.21 (Z69.010) Encounter for mental health services for victim of child sexual abuse
by parent
V61.21 (Z69.020) Encounter for mental health services for victim of nonparental child
sexual abuse
VI 5.41 (Z62.810) Personal history (past history) of sexual abuse in childhood
V61.22 (Z69.011 ) Encounter for mental health services for perpetrator of parental child
sexual abuse
V62.83 (Z69.021) Encounter for mental health services for peφetrator of nonparental
child sexual abuse
Child Neglect
Child neglect is defined as any confirmed or suspected egregious act or omission by a
child's parent or other caregiver that deprives the child of basic age-appropriate needs and
thereby results, or has reasonable potential to result, in physical or psychological harm to
the child. Child neglect encompasses abandonment; lack of appropriate supervision; failure to attend to necessary emotional or psychological needs; and failure to provide necessary education, medical care, nourishment, shelter, and/or clothing.
Child Neglect, Confirmed
995.52 (T74.02XA) Initial encounter
995.52 (T74.02XD) Subsequent encounter
Child Neglect, Suspected
995.52 (T76.02XA) Initial encounter
995.52 (T76.02XD) Subsequent encounter
Other Circumstances Related to Child Neglect
V61.21 (Z69.010) Encounter for mental health services for victim of child neglect by
parent
V61.21 (Z69.020) Encounter for mental health services for victim of nonparental child
neglect
VI 5.42 (Z62.812) Personal history (past history) of neglect in childhood
V61.22 (Z69.011 ) Encounter for mental health services for perpetrator of parental child
neglect
V62.83 (Z69.021) Encounter for mental health services for perpetrator of nonparental
child neglect
Child Psychological Abuse
Child psychological abuse is nonaccidental verbal or symbolic acts by a child's parent or
caregiver that result, or have reasonable potential to result, in significant psychological
harm to the child. (Physical and sexual abusive acts are not included in this category.) Examples of psychological abuse of a child include berating, disparaging, or humiliating
the child; threatening the child; harming/abandoning—or indicating that the alleged
offender will harm/abandon—people or things that the child cares about; confining the
child (as by tying a child's arms or legs together or binding a child to furrüture or another
object, or confining a child to a small enclosed area [e.g., a closet]); egregious scapegoating
of the child; coercing the child to inflict pain on himself or herself; and disciplining the
child excessively (i.e., at an extremely high frequency or duration, even if not at a level of
physical abuse) through physical or nonphysical means.
Child Psychological Abuse, Confirmed
995.51 (T74.32XA) Initial encounter
995.51 (T74.32XD) Subsequent encounter
Child Psychological Abuse, Suspected
995.51 (T76.32XA) Inihal encounter
995.51 (T76.32XD) Subsequent encounter
Other Circumstances Related to Child Psychological Abuse
V61.21 (Z69.010) Encounter for mental health services for victim of child psychological
abuse by parent
V61.21 (Z69.020) Encounter for mental health services for victim of nonparental child
psychological abuse
VI 5.42 (Z62.811 ) Personal history (past history) of psychological abuse in childhood
V61.22 (Z69.011 ) Encounter for mental health services for peφetrator of parental child
psychological abuse
V62.83 (Z69.021 ) Encounter for mental health services for perpetrator of nonparental
child psychological abuse
Adult Maltreatm ent and Neglect Problems
Spouse or Partner Violence, Physical
This category should be used when nonaccidental acts of physical force that result, or have
reasonable potential to result, in physical harm to an intimate partner or that evoke significant fear in the partner have occurred during the past year. Nonaccidental acts of physical
force include shoving, slapping, hair pulling, pinching, restraining, shaking, throwing,
biting, kicking, hitting with the fist or an object, burning, poisoning, applying force to the
throat, cutting off the air supply, holding the head under water, and using a weapon. Acts
for the purpose of physically protecting oneself or one's partner are excluded.
Spouse or Partner Violence, Physical, Confirmed
995.81 (T74.11XA) Initialencounter
995.81 (T74.11XD) Subsequent encounter
Spouse or Partner Violence, Physical, Suspected
995.81 (T76.11XA) Initialencounter
995.81 (T76.11XD) Subsequent encounter
Other Circumstances Related to Spouse or Partner Violence, Physical
V61.11 (Z69.11) Encounter for mental health services for victim of spouse or partner
violence, physical
VI 5.41 (Z91.410) Personal history (past history) of spouse or partner violence, physical
V61.12 (Z69.12) Encounter for mental health services for perpetrator of spouse or
partner violence, physical
Spouse or Partner Violence, Sexual
This category should be used when forced or coerced sexual acts with an intimate partner
have occurred during the past year. Sexual violence may involve the use of physical force
or psychological coercion to compel the partner to engage in a sexual act against his or her
will, whether or not the act is completed. Also included in this category are sexual acts
with an intimate partner who is unable to consent.
Spouse or Partner Violence, Sexual, Confirmed
995.83 (T74.21 XA) Initial encounter
995.83 (T74.21XD) Subsequent encounter
Spouse or Partner Violence, Sexual, Suspected
995.83 (T76.21 XA) Initial encounter
995.83 (T76.21XD) Subsequent encounter
Other Circumstances Related to Spouse or Partner Violence, Sexual
V61.11 (Z69.81) Encounter for mental health services for victim of spouse or partner
violence, sexual
VI 5.41 (Z91.410) Personal history (past history) of spouse or partner violence, sexual
V61.12 (Z69.12) Encounter for mental health services for perpetrator of spouse or
partner violence, sexual
Spouse or Partner Neglect
Partner neglect is any egregious act or omission in the past year by one partner that deprives a dependent partner of basic needs and thereby results, or has reasonable potential
to result, in physical or psychological harm to the dependent partner. This category is used
in the context of relationships in which one partner is extremely dependent on the other
partner for care or for assistance in navigating ordinary daily activities—for example, a
partner who is incapable of self-care owing to substantial physical, psychological/intellectual, or cultural limitations (e.g., inability to communicate with others and manage everyday activities due to living in a foreign culture).
Spouse or Partner Neglect, Confirmed
995.85 (T74.01 XA) Initial encounter
995.85 (T74.01 XD) Subsequent encounter
Spouse or Partner Neglect, Suspected
995.85 (T76.01 XA) Initial encounter
995.85 (T76.01XD) Subsequent encounter
Other Circumstances Related to Spouse or Partner Neglect
V61.11 (Z69.11) Encounter for mental health services for victim of spouse or partner
neglect
V15.42 (Z91.412) Personal history (past history) of spouse or partner neglect
V61.12 (Z69.12) Encounter for mental health services for perpetrator of spouse or
partner neglect
Spouse or Partner Abuse, Psychological
Partner psychological abuse encompasses nonaccidental verbal or symbolic acts by one
partner that result, or have reasonable potential to result, in significant harm to the other
partner. This category should be used when such psychological abuse has occurred during
the past year. Acts of psychological abuse include berating or humiliating the victim; interrogating the victim; restricting tiie victim's ability to come and go freely; obstructing the victim's access to assistance (e.g., law enforcement; legal, protective, or medical resources);
threatening the victim with physical harm or sexual assault; harming, or threatening to
harm, people or things that the victim cares about; unwarranted restriction of the victim's access to or use of economic resources; isolating the victim from family, friends, or social support resources; stalking the victim; and trying to make the victim think that he or she is crazy.
Spouse or Partner Abuse, Psychological, Confirmed
995.82 (T74.31 XA) Initial encounter
995.82 (174.31 XD) Subsequent encounter
Spouse or Partner Abuse, Psychological, Suspected
995.82 (T76.31 XA) Initial encounter
995.82 (T76.31XD) Subsequent encounter
Other Circumstances Related to Spouse or Partner Abuse, Psychological
V61.11 (Z69.11) Encounter for mental health services for victim of spouse or partner
psychological abuse
V15.42 (Z91.411 ) Personal history (past history) of spouse or partner psychological abuse
V61.12 (Z69.12) Encounter for mental health services for perpetrator of spouse or partner psychological abuse
Adult Abuse by Nonspouse or Nonpartner
These categories should be used when an adult has been abused by another adult who is
not an intimate partner. Such maltreatment may involve acts of physical, sexual, or emotional abuse. Examples of adult abuse include nonaccidental acts of physical force (e.g.,
pushing/shoving, scratching, slapping, throwing something that could hurt, punching,
biting) that have resulted—or have reasonable potential to result—in physical harm or
have caused significant fear; forced or coerced sexual acts; and verbal or symbolic acts
with the potential to cause psychological harm (e.g., berating or humiliating the person;
interrogating the person; restricting the person's ability to come and go freely; obstructing
the person's access to assistance; threatening the person; harming or threatening to harm
people or things that the person cares about; restricting the person's access to or use of economic resources; isolating the person from family, friends, or social support resources;
stalking the person; trying to make the person think that he or she is crazy). Acts for the
purpose of physically protecting oneself or the other person are excluded.
Adult Physical Abuse by Nonspouse or Nonpartner, Confirmed
995.81 (T74.11XA) Initialencounter
995.81 (T74.11XD) Subsequent encounter
Adult Physical Abuse by Nonspouse or Nonpartner, Suspected
995.81 (T76.11XA) Initialencounter
995.81 (T76.11XD) Subsequent encounter
Adult Sexual Abuse by Nonspouse or Nonpartner, Confirmed
995.83 (T74.21XA) Initialencounter
995.83 (T74.21 XD) Subsequent encounter
Adult Sexual Abuse by Nonspouse or Nonpartner, Suspected
995.83 (T76.21XA) Initial encounter
995.83 (T76.21XD) Subsequent encounter
Adult Psychological Abuse by Nonspouse or Nonpartner, Confirmed
995.82 (T74.31XA) Initialencounter
995.82 (T74.31 XD) Subsequent encounter
Adult Psychological Abuse by Nonspouse or Nonpartner, Suspected
995.82 (T76.31XA) Initial encounter
995.82 (T76.31XD) Subsequent encounter
Other Circumstances Related to Adult Abuse by Nonspouse or Nonpartner
V65.49 (Z69.81 ) Encounter for mental health services for victim of nonspousal or nonpartner adult abuse
V62.83 (Z69.82) Encounter for mental health services for perpetrator of nonspousal or
nonpartner adult abuse
Educational and Occupational Problems
\
Educational Problems
V62.3 (Z55.9) Academic or Educational Problem
This category should be used when an academic or educational problem is the focus of
clinical attention or has an impact on the individual's diagnosis, treatment, or prognosis.
Problems to be considered include illiteracy or low-level literacy; lack of access to schooling owing to unavailability or unattainability; problems with academic performance (e.g.,
failing school examinations, receiving failing marks or grades) or underachievement (below what would be expected given the individual's intellectual capacity); discord with
teachers, school staff, or other students; and any other problems related to education and/
or literacy.
Occupational Problems
V62.21 (Z56.82) Problem Related to Current Military Deployment Status
This category should be used when an occupational problem directly related to an individual's military deployment status is the focus of clinical attention or has an impact on the
individual's diagnosis, treatment, or prognosis. Psychological reactions to deployment are
not included in this category; such reactions would be better captured as an adjustment
disorder or another mental disorder.
V62.29 (Z56.9) Other Problem Related to Employment
This category should be used when an occupational problem is the focus of clinical attention or has an impact on the individual's treatment or prognosis. Areas to be considered
include problems with employment or in the work environment, including unemployment; recent change of job; threat of job loss; job dissatisfaction; stressful work schedule;
uncertainty about career choices; sexual harassment on the job; other discord with boss,
supervisor, co-workers, or others in the work environment; uncongenial or hostile work
environments; other psychosocial stressors related to work; and any other problems related to employment and/or occupation.
Housing and Economic Problems
Housing Problems
V60.0 (Z59.0) Homelessness
This category should be used when lack of a regular dwelling or living quarters has an impact on an individual's treatment or prognosis. An individual is considered to be homeless
if his or her primary nighttime residence is a homeless shelter, a warming shelter, a domestic violence shelter, a public space (e.g., tunnel, transportation station, mall), a building not intended for residential use (e.g., abandoned structure, unused factory), a
cardboard box or cave, or some other ad hoc housing situation.
V60.1 (Z59.1) Inadequate Housing
This category should be used when lack of adequate housing has an impact on an individual's treatment or prognosis. Examples of inadequate housing conditions include lack of
heat (in cold temperatures) or electricity, infestation by insects or rodents, inadequate
plumbing and toilet facilities, overcrowding, lack of adequate sleeping space, and excessive noise. It is important to consider cultural norms before assigning this category.
V60.89 (Z59.2) Discord With Neighbor, Lodger, or Landlord
This category should be used when discord with neighbors, lodgers, or a landlord is a focus of clinical attention or has an impact on the individual's treatment or prognosis.
V60.6 (Z59.3) Problem Related to Living in a Residential Institution
This category should be used when a problem (or problems) related to living in a residential institution is a focus of clinical attention or has an impact on the individual's treatment
or prognosis. Psychological reactions to a change in living situation are not included in this
category; such reactions would be better captured as an adjustment disorder.
Economic Problems
V60.2 (Z59.4) Lack of Adequate Food or Safe Drinking Water
V60.2 (Z59.5) Extreme Poverty
V60.2 (Z59.6) Low Income
V60.2 (Z59.7) Insufficient Social Insurance or Welfare Support
This category should be used for individuals who meet eligibility criteria for social or welfare support but are not receiving such support, who receive support that is insufficient to
address their needs, or who otherwise lack access to needed insurance or support programs. Examples include inability to qualify for welfare support owing to lack of proper
documentation or evidence of address, inability to obtain adequate health insurance because of age or a preexisting condition, and denial of support owing to excessively stringent income or other requirements.
V60.9 (Z59.9) Unspecified Housing or Economic Problem
This category should be used when there is a problem related to housing or economic circumstances other than as specified above.
Other Problems Related to the Social Enviroriment
V62.89 (Z60.0) Phase of Life Problem
This category should be used when a problem adjusting to a life-cycle transition (a particular developmental phase) is the focus of clinical attention or has an impact on the individual's treatment or prognosis. Examples of such transitions include entering or
completing school, leaving parental control, getting married, starting a new career, becoming a parent, adjusting to an "empty nest" after children leave home, and retiring.
V60.3 (Z60.2) Problem Related to Living Alone
This category should be used when a problem associated with living alone is the focus of
clinical attention or has an impact on the individual's treatment or prognosis. Examples of
such problems include chronic feelings of loneliness, isolation, and lack of structure in carrying out activities of daily living (e.g., irregular meal and sleep schedules, inconsistent
performance of home maintenance chores).
V62.4 (Z60.3) Acculturation Difficulty
This category should be used when difficulty in adjusting to a new culture (e.g., following
migration) is the focus of clinical attention or has an impact on the individual's treatment
or prognosis.
V62.4 (Z60.4) Social Exclusion or Rejection
This category should be used when there is an imbalance of social power such that there is
recurrent social exclusion or rejection by others. Examples of social rejection include bullying, teasing, and intimidation by others; being targeted by others for verbal abuse and
humiliation; and being purposefully excluded from the activities of peers, workmates, or
others in one's social environment.
V62.4 (Z60.5) Target of (Perceived) Adverse Discrimination or Persecution
This category should be used when there is perceived or experienced discrimination
against or persecution of the individual based on his or her membership (or perceived
membership) in a specific category. Typically, such categories include gender or gender
identity, race, ethnicity, religion, sexual orientation, country of origin, political beliefs, disability status, caste, social status, weight, and physical appearance.
V62.9 (Z60.9) Unspecified Problem Related to Social Environment
This category should be used when there is a problem related to the individual's social environment other than as specified above.
Problems Related to Crime or Interaction
With the Legal System
V62.89 (Z65.4) Victim of Crime
V62.5 (Z65.0) Conviction in Civil or Criminal Proceedings Without Imprisonment
V62.5 (Z65.1) Imprisonment or Other Incarceration
V62.5 (Z65.2) Problems Related to Release From Prison
V62.5 (Z65.3) Problems Related to Other Legal Circumstances
Other Health Service Encounters for
Counseling and Medical Advice
V65.49 (Z70.9) Sex Counseling
This category should be used when the individual seeks counseling related to sex education, sexual behavior, sexual orientation, sexual attitudes (embarrassment, timidity), others' sexual behavior or orientation (e.g., spouse, partner, child), sexual enjoyment, or any
other sex-related issue.
V65.40 (Z71.9) Other Counseling or Consultation
This category should be used when counseling is provided or advice/consultation is
sought for a problem that is not specified above or elsewhere in this chapter. Examples include spiritual or religious counseling, dietary counseling, and counseling on nicotine use.
Problems Related to Other Psychosocial, Personal,
and Environmental Circumstances
V62.89 (Z65.8) Religious or Spiritual Problem
This category can be used when the focus of clinical attention is a religious or spiritual
problem. Examples include distressing experiences that involve loss or questioning of
faith, problems associated with conversion to a new faith, or questioning of spiritual values that may not necessarily be related to an organized church or religious institution.
V61.7 (Z64.0) Problems Related to Unwanted Pregnancy
V61.5 (Z64.1) Problems Related to Multiparity
V62.89 (Z64.4) Discord With Social Service Provider, Including Probation Officer,
Case Manager, or Social Services Worker
V62.89 (Z65.4) Victim of Terrorism or Torture
V62.22 (Z65.5) Exposure to Disaster, War, or Other Hostilities
V62.89 (Z65.8) Other Problem Related to Psychosocial Circumstances
V62.9 (Z65.9) Unspecified Problem Related to Unspecified Psychosocial Circumstances
Other Circumstances of Personal History
V15.49 (Z91.49) Other Personal History of Psychological Trauma
V15.59 (Z91.5) Personal History of Self-Harm
V62.22 (Z91.82) Personal History of Military Deployment
V15.89 (Z91.89) Other Personal Risk Factors
V69.9 (Z72.9) Problem Related to Lifestyle
This category should be used when a lifestyle problem is a specific focus of treatment or directly affects the course, prognosis, or treatment of a mental or other medical disorder. Examples of lifestyle problems include lack of physical exercise, inappropriate diet, high-risk
sexual behavior, and poor sleep hygiene. A problem that is attributable to a symptom of a
mental disorder should not be coded unless that problem is a specific focus of treatment or
directly affects the course, prognosis, or treatment of the individual. In such cases, both the
mental disorder and the lifestyle problem should be coded.
V71.01 (Z72.811 ) Adult Antisocial Behavior
This category can be used when the focus of clinical attention is adult antisocial behavior
that is not due to a mental disorder (e.g., conduct disorder, antisocial personality disorder). Examples include the behavior of some professional thieves, racketeers, or dealers in
illegal substances.
V71.02 (Z72.810) Child or Adolescent Antisocial Behavior
This category can be used when the focus of clinical attention is antisocial behavior in a
child or adolescent that is not due to a mental disorder (e.g., intermittent explosive disorder, conduct disorder). Examples include isolated antisocial acts by children or adolescents (not a pattern of antisocial behavior).
Problems Related to Access to Medical
and Other Health Care
V63.9 (Z75.3) Unavailability or Inaccessibility of Health Care Facilities
V63.8 (Z75.4) Unavailability or Inaccessibility of Other Helping Agencies
Nonadherence to Medical Treatment
V15.81 (Z91.19) Nonadherence to Medical Treatment
This category can be used when the focus of clinical attention is nonadherence to an important aspect of treatment for a mental disorder or another medical condition. Reasons
for such nonadherence may include discomfort resulting from treatment (e.g., medication
side effects), expense of treatment, personal value judgments or religious or cultural beliefs about the proposed treatment, age-related debility, and the presence of a mental disorder (e.g., schizophrenia, personality disorder). This category should be used only when
the problem is sufficiently severe to warrant independent clinical attention and does not
meet diagnostic criteria for psychological factors affecting other medical conditions.
278.00 (E66.9) Overweight or Obesity
This category may be used when overweight or obesity is a focus of clinical attention.
V65.2 (Z76.5) Malingering
The essential feature of malingering is the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as
avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs. Under some circumstances, malingering may repre
sent adaptive behavior—for example, feigning illness while a captive of the enemy during
wartime. Malingering should be strongly suspected if any combination of the following is
noted:
1. Medicolegal context of presentation (e.g., the individual is referred by an attorney to
the clinician for examination, or the individual self-refers while litigation or criminal
charges are pending).
2. Marked discrepancy between the individual's claimed stress or disability and the objective findings and observations.
3. Lack of cooperation during the diagnostic evaluation and in complying with the prescribed treatment regimen.
4. The presence of antisocial personality disorder.
Malingering differs from factitious disorder in that the motivation for the symptom
production in malingering is an external incentive, whereas in factitious disorder external
incentives are absent. Malingering is differentiated from conversion disorder and somatic
symptom-related mental disorders by the intentional production of symptoms and by the
obvious external incentives associated with it. Definite evidence of feigning (such as clear
evidence that loss of function is present during the examination but not at home) would
suggest a diagnosis of factitious disorder if the individual's apparent aim is to assume the
sick role, or malingering if it is to obtain an incentive, such as money.
V40.31 (Z91.83) Wandering Associated With a Mental Disorder
This category is used for individuals with a mental disorder whose desire to walk about
leads to significant clinical management or safety concerns. For example, individuals with
major neurocognitive or neurodevelopmental disorders may experience a restless urge to
wander that places them at risk for falls and causes them to leave supervised settings without needed accompaniment. This category excludes individuals whose intent is to escape
an unwanted housing situation (e.g., children who are running away from home, patients
who no longer wish to remain in the hospital) or those who walk or pace as a result of medication-induced akathisia.
Coding note: First code associated mental disorder (e.g., major neurocognitive disorder, autism spectrum disorder), then code V40.31 (Z91.83) wandering associated with
[specific mental disorder].
V62.89 (R41.83) Borderline Intellectual Functioning
This category can be used when an individual's borderline intellectual functioning is the focus of clinical attention or has an impact on the individual's treatment or prognosis. Differentiating borderline intellectual functioning and mild intellectual disability (intellectual
developmental disorder) requires careful assessment of intellectual and adaptive functions
and their discrepancies, particularly in the presence of co-occurring mental disorders that
may affect patient compliance with standardized testing procedures (e.g., schizophrenia or
attention-deficit/hyperactivity disorder with severe impulsivity).
: -ζ ' - ' i ; - ---- - S E C T IQ IIlll
Eilniefgmg MçasUrés and Mogels
Assessment Measures............................................................................ 733
Cross-Cutting Symptom Measures.................................................... 734
DSM-5 Self-Rated Level 1 Cross-Cutting
Symptom Measure—Adult........................................................ 738
Parent/Guardian-Rated DSM-5 Level 1 Cross-Cutting
Symptom Measure—Child Age 6 -1 7 ...................................... 740
Clinician-Rated Dimensions of Psychosis Symptom Severity.......... 742
World Health Organization Disability Assessment Schedule 2.0
(WHODAS 2.0).................................................................................. 745
Cultural Formulation................................................................................ 749
Cultural Formulation Interview (CFI).................................................... 750
Cultural Formulation Interview (CFI)—Informant Version..................755
Alternative DSM-5 Model for Personality Disorders.............................. 761
Conditions for Further Study.................................................................. 783
Attenuated Psychosis Syndrome........................................................ 783
Depressive Episodes With Short-Duration Hypomania....................786
Persistent Complex Bereavement Disorder...................................... 789
Caffeine Use Disorder.......................................................................... 792
Internet Gaming Disorder.................................................................... 795
Neurobehavioral Disorder Associated With
Prenatal Alcohol Exposure.............................................................. 798
Suicidal Behavior Disorder.................................................................. 801
Nonsuicidal Self-Injury........................................................................ 803
This section contains tools and techniques to enhance the clinical decision-making process, understand the cultural context of mental disorders, and
recognize emerging diagnoses for further study. It provides strategies to enhance clinical practice and new criteria to stimulate future research, representing a dynamic DSM-5 that will evolve with advances in the field.
Among the tools in Section III is a Level 1 cross-cutting self/informant-rated
measure that serves as a review of systems across mental disorders. A clinician-rated severity scale for schizophrenia and other psychotic disorders also
is provided, as well as the World Health Organization Disability Assessment
Schedule, Version 2 (WHODAS 2.0). Level 2 severity measures are available
online (www.psychiatry.org/dsm5) and may be used to explore significant responses to the Level 1 screen. A comprehensive review of the cultural context
of mental disorders, and the Cultural Formulation Interview (CFI) for clinical use,
are provided.
Proposed disorders for future study are provided, which include a new
model for the diagnosis of personality disorders as an alternative to the established diagnostic criteria; the proposed model incorporates impairments in personality functioning as well as pathological personality traits. Also included are
new conditions that are the focus of active research, such as attenuated psychosis syndrome and nonsuicidal self-injury.
Assessrilbnt
Measures
A growing body of scientific evidence favors dimensional concepts in the diagnosis
of mental disorders. The limitations of a categorical approach to diagnosis include the failure to find zones of rarity between diagnoses (i.e., delineation of mental disorders from one
another by natural boundaries), the need for intermediate categories like schizoaffective disorder, high rates of comorbidity, frequent not-otherwise-specified (NOS) diagnoses, relative
lack of utility in furthering the identification of unique antecedent validators for most mental disorders, and lack of treatment specificity for the various diagnostic categories.
From both clinical and research perspectives, there is a need for a more dimensional
approach that can be combined with DSM's set of categorical diagnoses. Such an approach
incorporates variations of features within an individual (e.g., differential severity of individual symptoms both within and outside of a disorder's diagnostic criteria as measured
by intensity, duration, or number of symptoms, along with other features such as type and
severity of disabilities) rather than relying on a simple yes-or-no approach. For diagnoses
for which all symptoms are needed for a diagnosis (a monothetic criteria set), different severity levels of the constituent symptoms may be noted. If a threshold endorsement of
multiple symptoms is needed, such as at least five of nine symptoms for major depressive
disorder (a polythetic criteria set), both severity levels and different combinations of the
criteria may identify more homogeneous diagnostic groups.
A dimensional approach depending primarily on an individual's subjective reports of
symptom experiences along with the clinician's interpretation is consistent with current
diagnostic practice. It is expected that as our understanding of basic disease mechanisms
based on pathophysiology, neurocircuitry, gene-environment interactions, and laboratory
tests increases, approaches that integrate both objective and subjective patient data will be
developed to supplement and enhance the accuracy of the diagnostic process.
Cross-cutting symptom measures modeled on general medicine's review of systems can
serve as an approach for reviewing critical psychopathological domains. The general medical review of systems is crucial to detecting subtle changes in different organ systems that
can facilitate diagnosis and treatment. A similar review of various mental functions can
aid in a more comprehensive mental status assessment by drawing attention to symptoms
that may not fit neatly into the diagnostic criteria suggested by the individual's presenting
symptoms, but may nonetheless be important to the individual's care. The cross-cutting
measures have two levels: Level 1 questions are a brief survey of 13 symptom domains for
adult patients and 12 domains for child and adolescent patients. Level 2 questions provide
a more in-depth assessment of certain domains. These measures were developed to be
administered both at initial interview and over time to track the patient's symptom status
and response to treatment.
Severity measures are disorder-specific, corresponding closely to the criteria that constitute the disorder definition. They may be administered to individuals who have received
a diagnosis or who have a clinically significant syndrome that falls short of meeting full
criteria for a diagnosis. Some of the assessments are self-completed by the individual,
while others require a clinician to complete. As with the cross-cutting symptom measures,
these measures were developed to be administered both at initial interview and over time
to track the severity of the individual's disorder and response to treatment.
The World Health Organization Disability Assessment Schedule, Version 2.0 (WHODAS 2.0)
was developed to assess a patient's ability to perform activities in six areas: understanding
and communicating; getting around; self-care; getting along with people; life activities
(e.g., household, work/school); and participation in society. The scale is self-administered
and was developed to be used in patients with any medical disorder. It corresponds to
concepts contained in the WHO International Classification of Functioning, Disability
and Health. This assessment can also be used over time to track changes in a patient's disabilities.
This chapter focuses on the DSM-5 Level 1 Cross-Cutting Symptom Measure (adult
self-rated and parent/guardian versions); the Clinician-Rated Dimensions of Psychosis
Symptom Severity; and the WHODAS 2.0. Clinician instructions, scoring information,
and interpretation guidelines are included for each. These measures and additional
dimensional assessments, including those for diagnostic severity, can be found online at
www.psychiatry.org/dsmS.
Cross-Cutting Symptom Measures
Level 1 Cross-Cutting Symptom Measure
The DSM-5 Level 1 Cross-Cutting Symptom Measure is a patient- or informant-rated measure that assesses mental health domains that are important across psychiatric diagnoses.
It is intended to help clinicians identify additional areas of inquiry that may have significant impact on the individual's treatment and prognosis. In addition, the measure may be
used to track changes in the individual's symptom presentation over time.
The adult version of the measure consists of 23 questions that assess 13 psychiatric domains, including depression, anger, mania, anxiety, somatic symptoms, suicidal ideation,
psychosis, sleep problems, memory, repetitive thoughts and behaviors, dissociation, personality functioning, and substance use (Table 1). Each domain consists of one to three
questions. Each item inquires about how much (or how often) the individual has been
bothered by the specific symptom during the past 2 weeks. If the individual is of impaired
capacity and unable to complete the form (e.g., an individual with dementia), a laiowledgeable adult informant may complete this measure. The measure was found to be clinically useful and to have good reliability in the DSM-5 field trials that were conducted in
adult clinical samples across the United States and in Canada.
The parent/guardian-rated version of the measure (for children ages 6-17) consists of
25 questions that assess 12 psychiatric domains, including depression, anger, irritability,
mania, anxiety, somatic symptoms, inattention, suicidal ideation/attempt, psychosis,
sleep disturbance, repetitive thoughts and behaviors, and substance use (Table 2). Each
item asks the parent or guardian to rate how much (or how often) his or her child has been
bothered by the specific psychiatric symptom during the past 2 weeks. The measure was
also found to be clinically useful and to have good reliability in the DSM-5 field trials that
were conducted in pediatric clinical samples across the United States. For children ages
11-17, along with the parent/guardian rating of the child's symptoms, the clinician may
consider having the child complete the child-rated version of the measure. The child-rated
version of the measure can be found online at www.psychiatry.org/dsm5.
Scoring and interpretation. On the adult self-rated version of the measure, each item is
rated on a 5-point scale (O=none or not at all; l=slight or rare, less than a day or two; 2=mild
or several days; 3=moderate or more than half the days; and 4=severe or nearly every day).
The score on each item within a domain should be reviewed. However, a rating of mild (i.e.,
2) or greater on any item within a domain, except for substance use, suicidal ideation, and
psychosis, may serve as a guide for additional inquiry and follow-up to determine if a more
detailed assessment is necessary, which may include the Level 2 cross-cutting symptom assessment for the domain (see Table 2). For substance use, suicidal ideahon, and psychosis, a
TA B LE 1 Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure:
13 domains, thresholds for further inquiry, and associated DSM-5
Level 2 measures
Domain Domain name
Threshold to guide DSM-5 Level 2 Cross-Cutting Symptom
further inquiry Measure®
I. Depression Mild or greater Level 2—Depression—Adult (PROMIS
Emotional Distress—Short Form)
II. Anger Mild or greater Level 2—Anger—Adult (PROMIS Emotional Distress—Anger—Short Form)
III. Mania Mild or greater Level 2—Mania—Adult (Altman Self-Rating
Mania Scale [ASRM])
IV. Anxiety Mild or greater Level 2—Anxiety—Adult (PROMIS
Emotional Distress—Anxiety—Short
Form)
V. Somatic symptoms Mild or greater Level 2—Somatic Symptom—Adult (Patient
Health Questionnaire-15
[PHQ-15] Somatic Symptom Severity
Scale)
VI. Suicidal ideation Slight or greater None
VII. Psychosis Slight or greater None
VIII. Sleep problems Mild or greater Level 2—Sleep Disturbance—Adult
(PROMIS Sleep Disturbance—Short Form)
IX. Memory Mild or greater None
X. Repetitive thoughts
and behaviors
Mild or greater Level 2—Repetitive Thoughts and
Behaviors—Adult (Florida ObsessiveCompulsive Inventory [FOCI] Severity
Scale)
XI. Dissociation Mild or greater None
XII. Personality
functioning
Mild or greater None
XIII. Substance use Slight or greater Level 2—Substance Use—Adult (adapted
from the NIDA-Modified ASSIST)
Note. NIDA=National Institute on Drug Abuse.
^Available at www.psychiatry.org/dsm5.
rating of slight (i.e., 1) or greater on any item within the domain may serve as a guide for additional inquiry and follow-up to determine if a more detailed assessment is needed. As
such, indicate the highest score within a domain in the "Highest domain score" column.
Table 1 outlines threshold scores that may guide further inquiry for the remaining domains.
On the parent/guardian-rated version of the measure (for children ages 6-17), 19 of the 25
items are each rated on a 5-point scale (O=none or not at aU; l=slight or rare, less than a day or
two; 2=mild or several days; 3=moderate or more than half the days; and 4=severe or nearly
every day). The suicide ideation, suicide attempt, and substance abuse items are each rated on
a "Yes, No, or Don't Know" scale. The score on each item within a domain should be reviewed. However, with the exception of inattention and psychosis, a rating of mild (i.e., 2) or
greater on any item within a domain that is scored on the 5-point scale may serve as a guide
for additional inquiry and follow-up to determine if a more detailed assessment is necessary,
which may include the Level 2 cross-cutting symptom assessment for the domain (see
Table 2). For inattention or psychosis, a rating of slight or greater (i.e., 1 or greater) may be
TABLE 2 Parent/guardian-rated DSM-5 Level 1 Cross-Cutting Symptom Measure
for child age 6 -1 7 :1 2 domains, thresholds for further inquiry, and
associated Level 2 measures
Domain Domain name
Threshold to guide DSM-5 Level 2 Cross-Cutting Symptom
further inquiry Measure®
I. Somatic symptoms Mild or greater Level 2—Somatic Symptoms—Parent/Guardian of Child Age 6-17 (Patient Health
Questionnaire-15 Somatic Symptom Severity Scale [PHQ-15])
II. Sleep problems Mild or greater Level 2—Sleep Disturbance—Parent/Guardian of Child Age 6-17 (PROMIS Sleep
Disturbance—Short Form)^
III. Inattention Slight or greater Level 2—Inattention—Parent/Guardian of
Child Age 6-17 (Swanson, Nolan, and Pelham, Version IV [SNAP-IV])
IV. Depression Mild or greater Level 2—Depression—Parent/Guardian of
Child Age 6-17 (PROMIS Emotional Distress—Depression—Parent Item Bank)
V. Anger Mild or greater Level 2—Anger—Parent/Guardian of Child
(PROMIS Calibrated Anger Measure—Parent)
VI. Irritability Mild or greater Level 2—Irritability—Parent/Guardian of
Child (Affective Reactivity Index [ARI])
VII. Mania Mild or greater Level 2—Mania—Parent/Guardian of Child
Age 6-17 (Altman Self-Rating Mania Scale
[ASRM])
VIII. Anxiety Mild or greater Level 2—Anxiety—Parent/Guardian of Child
Age 6-17 (PROMIS Emotional Distress—
Anxiety—Parent Item Bank)
IX. Psychosis Slight or greater None
X. Repetitive thoughts Mild or greater
and behaviors
None
XI. Substance use Yes
Don't Know
Level 2—Substance Use—Parent/Guardian of
Child (adapted from the NIDA-modified
ASSIST)
NIDA-modified ASSIST (adapted)—
Child-Rated (age 11-17 years)
XII. Suicidal ideation/
suicide attempts
Yes
Don't Know
None
None
Note. NIDA=National Institute on Drug Abuse.
^Available at www.psychiatry.org/dsm5.
used as an indicator for additional inquiry. A parent or guardian's rating of "Don't Know" on
the suicidal ideation, suicide attempt, and any of the substance use items, especially for children ages 11-17 years, may result in additional probing of the issues with the child, including
using tiie child-rated Level 2 Cross-Cutting Symptom Measure for the relevant domain. Because additional inquiry is made on the basis of the highest score on any item within a domain, clinicians should indicate that score in the "Highest Domain Score" column. Table 2
outlines threshold scores that may guide further inquiry for the remaining domains.
Level 2 Cross-Cutting Symptom Measures
Any threshold scores on the Level 1 Cross-Cutting Symptom Measure (as noted in Tables
1 and 2 and described in "Scoring and Interpretation" indicate a possible need for detailed
clinical inquiry. Level 2 Cross-Cutting Symptom Measures provide one method of obtaining more in-depth information on potentially significant symptoms to inform diagnosis,
treatment planning, and follow-up. They are available online at www.psychiatry.org/
dsmS. Tables 1 and 2 outline each Level 1 domain and identify the domains for which
DSM-5 Level 2 Cross-Cutting Symptom Measures are available for more detailed assessments. Adult and pediatric (parent and child) versions are available online for most Level
1 symptom domains at www.psychiatry.org/dsm5.
Frequency of Use of the Cross-Cutting
Symptom iVleasures
To track change in the individual's symptom presentation over time, the Level 1 and relevant Level 2 cross-cutting symptom measures may be completed at regular intervals as
clinically indicated, depending on the stability of the individual's symptoms and treatment status. For individuals with impaired capacity and for children ages 6-17 years, it is
preferable for the measures to be completed at follow-up appointments by the same
knowledgeable informant and by the same parent or guardian. Consistently high scores
on a particular domain may indicate significant and problematic symptoms for the individual that might warrant further assessment, treatment, and follow-up. Clinical judgment should guide decision making.
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Clinician-Rated Dimensions of
Psychosis Symptom Severity
As described in the chapter "Schizophrenia Spectrum and Other Psychotic Disorders,"
psychotic disorders are heterogeneous, and symptom severity can predict important aspects of the illness, such as the degree of cognitive and/or neurobiological deficits. Dimensional assessments capture meaningful variation in the severity of symptoms, which may
help with treatment planning, prognostic decision-making, and research on pathophysiological mechanisms. The Clinician-Rated Dimensions of Psychosis Symptom Severity
provides scales for the dimensional assessment of the primary symptoms of psychosis, including hallucinations, delusions, disorganized speech, abnormal psychomotor behavior,
and negative symptoms. A scale for the dimensional assessment of cognitive impairment
is also included. Many individuals with psychotic disorders have impairments in a range
of cogrutive domains, which predict functional abilities. In addition, scales for dimensional
assessment of depression and mania are provided, which may alert clinicians to mood pathology. The severity of mood symptoms in psychosis has prognostic value and guides
treatment.
The Clinician-Rated Dimensions of Psychosis Symptom Severity is an 8-item measure
that may be completed by the clinician at the time of the clinical assessment. Each item asks
the clinician to rate the severity of each symptom as experienced by the individual during
the past 7 days.
Scoring and Interpretation
Each item on the measure is rated on a 5-point scale (O=none; l=equivocal; 2=present, but
mild; 3=present and moderate; and 4=present and severe) with a symptom-specific definition of each rating level. The clinician may review all of the individual's available information and, based on clinical judgment, select (by circling) the level that most accurately
describes the severity of the individual's condition. The clinician then indicates the score
for each item in the "Score" column provided.
Frequency of Use
To track changes in the individual's symptom severity over time, the measure may be
completed at regular intervals as clinically indicated, depending on the stability of the individual's symptoms and treatment status. Consistently high scores on a particular domain may indicate significant and problematic areas for the individual that might warrant
further assessment, treatment, and follow-up. Clinical judgment should guide decision
making.
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World Health Organization
' Disability Assessment Schedule 2.0
The adult self-administered version of the World Health Organization Disability Assessment
Schedule 2.0 (WHODAS 2.0) is a 36-item measure that assesses disability in adults age 18
years and older. It assesses disability across six domains, including understanding and
communicating, getting around, sel^care, getting along with people, life activities (i.e.,
household, work, and/or school activities), and participation in society. If the adult individual is of impaired capacity and unable to complete the form (e.g., a patient with dementia), a knowledgeable informant may complete the proxy-administered version of the
measure, which is available at www.psychiatry.org/dsm5. Each item on the self-administered
version of the WHODAS 2.0 asks the individual to rate how much difficulty he or she has
had in specific areas of functioning during the past 30 days.
WHODAS 2.0 Scoring Instructions Provided by WHO
WHODAS 2.0 summary scores. There are two basic options for computing the summary
scores for the WHODAS 2.0 36-item full version.
Simple: The scores assigned to each of the items—"none" (1), "mild" (2), "moderate" (3),
"severe" (4), and "extreme" (5)—are summed. This method is referred to as simple scoring
because the scores from each of the items are simply added up without recoding or collapsing of response categories; thus, there is no weighting of individual items. This approach is
practical to use as a hand-scoring approach, and may be the method of choice in busy clinical settings or in paper-and-pencil interview situations. As a result, the simple sum of the
scores of the items across all domains constitutes a statistic that is sufficient to describe the
degree of functional limitations.
Complex: The more complex method of scoring is called "item-response-theory"
(IRT)-based scoring. It takes into account multiple levels of difficulty for each WHODAS
2.0 item. It takes the coding for each item response as "none," "mild," "moderate," "severe," and "extreme" separately, and then uses a computer to determine the summary
score by differentially weighting the items and the levels of severity. The computer program is available from the WHO Web site. The scoring has three steps:
• Step 1—Summing of recoded item scores within each domain.
• Step 2—Summing of all six domain scores.
• Step 3—Converting the summary score into a metric ranging from 0 to 100
(where 0=no disability; 100=full disability).
WHODAS 2.0 domain scores. WHODAS 2.0 produces domain-specific scores for six
different functioning domains: cognition, mobility, self-care, getting along, life activities
(household and work/school), and participation.
WHODAS 2.0 population nomris. For the population norms for IRT-based scoring of the
WHODAS 2.0 and for the population distribution of IRT-based scores for WHODAS 2.0,
please see www.who.int/classifications/icf/Pop_norms_distrib_IRT_scores.pdf.
Additional Scoring and interpretation Guidance for
DSiVI-5 Users
The clinician is asked to review the individual's response on each item on the measure
during the clinical interview and to indicate the self-reported score for each item in the section provided for "Clinician Use Only." However, if the clinician determines that the score
on an item should be different based on the clinical interview and other information avail
able, he or she may indicate a corrected score in the raw item score box. Based on findings
from the DSM-5 Field Trials in adult patient samples across six sites in the United States
and one in Canada, DSM-5 recommends calculation and use of average scores for each domain
and for general disability. The average scores are comparable to the WHODAS 5-point scale,
which allows the clinician to think of the individual's disability in terms of none (1), mild
(2), moderate (3), severe (4), or extreme (5). The average domain and general disability
scores were found to be reliable, easy to use, and clinically useful to the clinicians in the
DSM-5 Field Trials. The average domain score is calculated by dividing the raw domain score
by the number of items in the domain (e.g., if all the items within the "understanding and
communicating" domain are rated as being moderate then the average domain score
would be 18/6=3, indicating moderate disability). The average general disability score is calculated by dividing the raw overall score by number of items in the measure (i.e., 36). The
individual should be encouraged to complete all of the items on the WHODAS 2.0. If no response is given on 10 or more items of the measure (i.e., more than 25% of the 36 total
items), calculation of the simple and average general disability scores may not be helpful.
If 10 or more of the total items on the measure are missing but the items for some of the domains are 75%-100% complete, the simple or average domain scores may be used for those
domains.
Frequency of use. To track change in the individual's level of disability over time, the
measure may be completed at regular intervals as clinically indicated, depending on the
stabihty of the individual's symptoms and treatment status. Consistently high scores on a
particular domain may indicate significant and problematic areas for the individual that
might warrant further assessment and intervention.
Patient Name:
WHODAS 2.0
World Health Organization Disability Assessment Schedule 2.0
3 6 -ite m version , self-ad m in istered
_________________A g e:_______ Sex: □ Male □ Female Date:__________
This q u estio n n aire asks a b o u t difficulties d u e to h e a lth /m e n ta l h ealth co n d itio n s. H ealth con d itio n s include d is e a se s o r
illn esses, o th e r h e a lth p ro b le m s th a t m ay b e s h o rt o r long lastin g, in ju ries, m e n ta l o r e m o tio n a l p ro b le m s, an d p ro b lem s
w ith alcoh o l o r d ru g s. Think back o ver th e p a st 3 0 d a y s and an sw er th e s e q u estio n s thinking ab o u t how m uch difficulty you
had doing th e follow ing activities. For each q u estio n , p lease circle only o n e resp o n se.
Numeric scores assigned to each of the items: j ^ j 1 | ^ | 3 j 4 5
In th e last 30 d avs. how m u ch difficulty did you h ave in:
Understanding and communicating
D l.l Concentrating on doing something for ten minutes? None Mild M oderate Severe
Extreme or
cannot do
D1.2 Remembering to do imoortant things? None Mild Moderate Severe
Extreme or
cannot do
013 Analvzinfi and finding solutions to oroblems in dayNone Mild Moderate Severe
Ixtrem eo r
cannot do to-day life? “ “
D1.4
Learning a new task, for example, learning how to
get to a new place?
None Mild M oderate Severe
Extreme or
cannot do
D1.5 Generally understanding what people say? None Mild M oderate Severe
^Extreme or
cannot do
D1.6 Starting and maintaining a conversation? None Mild M oderate Severe
Extreme or
cannot do
Getting around
D2.1 Standing for long periods, such as 30 minutes? 1 None Mild Moderate Severe
Extreme or
cannot do
D2.2 Standing u d from sitting down? None Mild M oderate Severe
Extreme or
cannot do
D2.3 IMovIng around inside vour home? None Mild M oderate Severe
Extreme or
cannot do
D2.4 Gettingoutof vour home? None Mild M oderate Severe
Extreme or
cannot do
Walking a lone distance, such as a kilometer (or
E g a le n t)?
None Mild M oderate Severe
Extreme or
cannot do :
Self-care
D3:i washing vour whole bodv? None Mild M oderate Severe
Extreme or
cannot do
D3.2 Getting dressed? None Mild Moderate Severe
Extreme or
cannot do
D3.3 None Mild M oderate Severe
Extreme or
cannot do
D3.4 Staving bv yourself for a few days? None Mild M oderate Severe
Extreme or
cannot do
Getting along with people
D4.1 Dealing with people vou do not know? None Mild M oderate Severe
Extreme or
cannot do
D4.2 Maintaining a friendship? None Mild Moderate Severe
Extreme or
cannot do
D4.3 Getting along with people who are close to you? None Mild Moderate Severe
Extreme or
cannot do
D4.4 Making new friends? None Mild M oderate Severe
Extreme or
cannot do
D4.5 Sexual activities? None Mild M oderate Severe
Extreme or
cannot do
Clinician Use
Only
3 0
2 5
20
Clinician Use
Only -
Numeric scores assigned to each of the items: j 1 j ^ I ^ 1 I 5
1 «
| i s III In th e last 30 days, h ow m uch difficulty did you h ave in:
Life activities—Household
D5.1 Taking care of your household responsibilities? None ^ Mild M oderate Severe
Extreme or
cann otd o
20 5 ;■
D5.2 Doing most important household tasks well? None Mild M oderate Severe
Extreme or
cannot do
053 Getting ail of the household work done that you
needed to do? None ” M l # M oderate Severe
Extreme or
cannot do
D5.4 Getting vour household work done as auickiv as
needed? None Mild M oderate Severe
Extreme or
cannot do
Life activities—School/Work
If you work (paid, non-paid, self-employed) or go to school, complete questions D5.5-D5.8, below.
Otherwise, skip to D6.1.
Because of vour health condition, in the oast 30 days, how much difficultN did you have in:
0S.5 Your dav-to-dav work/school? - : None Miid M ^ ierate“ Severe“
Extreme or
cannot do
i
D5.6 Doing your most important work/school tasks well? None Mild M oderate Severe
Extreme or
cannot do
-
D5 7 Setting ail of the work done that you need to do? ~ None Mild M oderate Severe
Extreme or
cannot do
20 5
D5.8 Getting vour work done as auickiv as needed? None Mild M oderate Severe
Extreme or
cannot do
Participation in society
In the past 30 days:
06,1
How much of a problem did vou have In joining in
commimltv activities (for example, festivities. - ™ None Mild " Modeirate Severe
Extreme or
cannot do
40 5
retigious, or other activities) in the same way as.
anyone else can?
D6.2 How much of a problem did you have because of
None Mild M oderate Severe
Extreme or
cannot do
£^3
How much of a problem did vou have living with
dfgnitv because of the attitudes and actions of
p i» ? . , V ' ' ,
None Mild M oderate Severe
Extreme or
cannot do
D6.4 How much time did you spend on your health
condition or its consequences? None Some M oderate A Lot
Extreme or
cannot do
D6.5 much have vou been emotionaliv affected bv
None Mild Severe
Extreme or
health condition? cannot do
M oderate
D6.6 How much has vour health been a drain on the
inancial resources of you or your family?
None Mild M oderate Severe
Extreme or
cannot do
D6.7 How much of a problem did your family have
because of your health problems?
None Mitd M oderate Severe
Extreme or
cannot do
D6.8 How much of a problem did you have in doing
None Mild M oderate Severe
Extreme or
cannot do
G en eral Disability S co re (T otal): 180 5
© World Health Organization, 2012. All rights reserved. Measuring health and disability: manual for WHO Disability
Assessment Schedule (WHODAS 2.0), World Health Organization, 2010, Geneva.
The World Health Organization has granted the Publisher permission for the reproduction of this instrument. This material can
be reproduced without permission by clinicians for use with their own patients. Any other use, including electronic use,
requires written permission from WHO.
Cuitural
Formulation
UndGrStânding the cultursl context of niness experience is essential for effective diagnostic assessment and clinical management. Culture refers to systems of knowledge, concepts, rules, and practices that are learned and transmitted across generations.
Culture includes language, religion and spirituality, family structures, life-cycle stages,
ceremonial rituals, and customs, as well as moral and legal systems. Cultures are open,
dynamic systems that undergo continuous change over time; in the contemporary world,
most individuals and groups are exposed to multiple cultures, which they use to fashion
their own identities and make sense of experience. These features of culture make it crucial not to overgeneralize cultural information or stereotype groups in terms of fixed cultural traits.
Race is a culturally constructed category of identity that divides humanity into groups
based on a variety of superficial physical traits attributed to some hypothetical intrinsic,
biological characteristics. Racial categories and constructs have varied widely over history
and across societies. The construct of race has no consistent biological definition, but it is
socially important because it supports racial ideologies, racism, discrimination, and social
exclusion, which can have strong negative effects on mental health. There is evidence that
racism can exacerbate many psychiatric disorders, contributing to poor outcome, and that
racial biases' can affect diagnostic assessment.
Ethnicity is a culturally constructed group identity used to define peoples and communities. It may be rooted in a common history, geography, language, religion, or other shared
characteristics of a group, which distinguish that group from others. Ethrücity may be selfassigned or attributed by outsiders. Increasing mobility, intermarriage, and intermixing of
cultures has defined new mixed, multiple, or hybrid ethnic identities.
Culture, race, and ethnicity are related to economic inequities, racism, and discrimination that result in health disparities. Cultural, ethnic, and racial identities can be sources of
strength and group support that enhance resilience, but they may also lead to psychological, interpersonal, and intergenerational conflict or difficulties in adaptation that require
diagnostic assessment.
Outline for Cultural Formulation
The Outline for Cultural Formulation introduced in DSM-IV provided a framework for assessing information about cultural features of an individual's mental health problem and
how it relates to a social and cultural context and history. DSM-5 not only includes an updated version of the Outline but also presents an approach to assessment, using the Cultural Formulation Interview (CFI), which has been field-tested for diagnostic usefulness
among clinicians and for acceptability among patients.
The revised Outline for Cultural Formulation calls for systematic assessment of the following categories:
• Cultural identity of the individual: Describe the individual's racial, ethnic, or cultural
reference groups that may influence his or her relationships with others, access to re
sources, and developmental and current challenges, conflicts, or predicaments. For immigrants and racial or ethnic minorities, the degree and kinds of involvement with both
the culture of origin and the host culture or majority culture should be noted separately.
Language abilities, preferences, and patterns of use are relevant for identifying difficulties with access to care, social integration, and the need for an interpreter. Other clinically relevant aspects of identity may include religious affiliation, socioeconomic
background, personal and family places of birth and growing up, migrant status, and
sexual orientation.
• Cultural conceptualizations of distress: Describe the cultural constructs that influence
how the individual experiences, understands, and communicates his or her symptoms
or problems to others. These constructs may include cultural syndromes, idioms of distress, and explanatory models or perceived causes. The level of severity and meaning of
the distressing experiences should be assessed in relation to the norms of the individual's cultural reference groups. Assessment of coping and help-seeking patterns should
consider the use of professional as well as traditional, alternative, or complementary
sources of care.
• Psychosocial stressors and cultural features of vulnerability and resilience: Identify
key stressors and supports in the individual's social environment (which may include
both local and distant events) and the role of religion, family, and other social networks
(e.g., friends, neighbors, coworkers) in providing emotional, instrumental, and informational support. Social stressors and social supports vary with cultural interpretations of events, family structure, developmental tasks, and social context. Levels of
functioning, disability, and resilience should be assessed in light of the individual's cultural reference groups.
• Cultural features of the relationship between the individual and the clinician: Identify differences in culture, language, and social status between an individual and clinician that may cause difficulties in communication and may influence (diagnosis and
treatment. Experiences of racism and discrimination in the larger society may impede
establishing trust and safety in the clinical diagnostic encounter. Effects may include
problems eliciting symptoms, misunderstanding of the cultural and clinical significance of symptoms and behaviors, and difficulty establishing or maintaining the rapport needed for an effective clinical alliance.
• Overall cultural assessment: Summarize the implications of the components of the cultural formulation identified in earlier sections of the Outline for diagnosis and other
clinically relevant issues or problems as well as appropriate management and treatment intervention.
Cultural Formulation Interview (CFI)
The Cultural Formulation Interview (CFI) is a set of 16 questions that clinicians may use to
obtain information during a mental health assessment about the impact of culture on key
aspects of an individual's clinical presentation and care. In the CFI, culture refers to
• The values, orientations, knowledge, and practices that individuals derive from membership in diverse social groups (e.g., ethnic groups, faith communities, occupational
groups, veterans groups).
• Aspects of an individual's background, developmental experiences, and current social
contexts that may affect his or her perspective, such as geographical origin, migration,
language, religion, sexual orientation, or race/ethnicity.
• The influence of family, friends, and other community members (the individual's social
network) on the individual's illness experience.
The CFI is a brief semistructured interview for systematically assessing cultural factors
in the clinical enc;ounter that may be used with any individual. The CFI focuses on the individual's experience and the social contexts of the clinical problem. The CFI follows a person-centered approach to cultural assessment by eliciting information from the individual
about his or her own views and those of others in his or her social network. This approach
is designed to avoid stereotyping, in that each individual's cultural knowledge affects how
he or she interprets illness experience and guides how he or she seeks help. Because the
CFI concerns the individual's personal views, there are no right or wrong answers to these
questions. The interview follows and is available online at www.psychiatry.org/dsm5.
The CFI is formatted as two text columns. The left-hand column contains the instructions for administering the CFI and describes the goals for each interview domain. The
questions in the right-hand column illustrate how to explore these domains, but they are
not meant to be exhaustive. Follow-up questions may be needed to clarify individuals' answers. Questions may be rephrased as needed. The CFI is intended as a guide to cultural assessment and should be used flexibly to maintain a natural flow of the interview and rapport
with the individual.
The CFI is best used in conjunction with demographic information obtained prior to
the interview in order to tailor the CFI questions to address the individual's background
and current situation. Specific demographic domains to be explored with the CFI will vary
across individuals and settings. A comprehensive assessment may include place of birth,
age, gender, racial/ethnic origin, marital status, family composition, education, language
fluencies, sexual orientation, religious or spiritual affiliation, occupation, employment, income, and migration history.
The CFI can be used in the initial assessment of individuals in all clinical settings, regardless of the cultural background of the individual or of the clinician. Individuals and clinicians who appear to share the same cultural background may nevertheless differ in ways
that are relevant to care. The CFI may be used in its entirety, or components may be incorporated into a clinical evaluation as needed. The CFI may be especially helpful when there is
• Difficulty in diagnostic assessment owing to significant differences in the cultural, religious, or socioeconomic backgrounds of clinician and the individual.
• Uncertainty about the fit between culturally distinctive symptoms and diagnostic criteria.
• Difficulty in judging illness severity or impairment.
• Disagreement between the individual and clinician on the course of care.
• Limited engagement in and adherence to treatment by the individual.
The CFI emphasizes four domains of assessment: Cultural Definition of the Problem
(questions 1-3); Cultural Perceptions of Cause, Context, and Support (questions 4-10); Cultural Factors Affecting Self-Coping and Past Help Seeking (questions 11-13); and Cultural
Factors Affecting Current Help Seeking (questions 14-16). Both the person-centered process
of conducting the CFI and the information it elicits are intended to enhance the cultural validity of diagnostic assessment, facilitate treatment planning, and promote the individual's
engagement and satisfaction. To achieve these goals, the information obtained from the CFI
should be integrated with all other available clinical material into a comprehensive clinical
and contextual evaluation. An Informant version of the CFI can be used to collect collateral
information on the CFI domains from family members or caregivers.
Supplementary modules have been developed that expand on each domain of the CFI
and guide clinicians who wish to explore these domains in greater depth. Supplementary
modules have also been developed for specific populations, such as children and adolescents, elderly individuals, and immigrants and refugees. These supplementary modules
are referenced in the CFI under the pertinent subheadings and are available online at
www.psychiatry.org/dsm5.
Supplementary modules used to expand each CFI subtopic are noted in parentheses.
GUIDE TO INTERVIEWER
INSTRUCTIONS TO THE INTERVIEWER ARE
ITALICIZED,
The following questions aim to clarify key aspects of INTRODUCTION FOR THE INDIVIDUAL:
the presenting clinical problem from the point of
view of the individual and other members of the
individual's social network (i.e., family, friends, or
others involved in current problem). This includes
the problem's meaning, potential sources of help,
and expectations for services.
I would like to understand the problems that
bring you here so that I can help you more
effectively. I want to know about your experience and ideas. I will ask some questions
about what is going on and how you are dealing with it. Please remember there are no
right or wrong answers.
CULTURAL DEFINITION OF THE PROBLEM
Cultural Οερινιήον of the Problem
(Explanatory Model, Level of Functioning)
Elicit the individual's view o f core problems and key
concerns.
Focus on the individual's own way of understanding the problem.
Use the term, expression, or brief description elicited
in question 1 to identify the problem in subsequent
questions (e.g., "your conflict with your son").
Ask how individual frames the problem for members
of the social network.
Focus on the aspects o f the problem that matter most
to the individual.
2.
3.
What brings you here today?
IF INDIVIDUAL GIVES FEW DETAILS OR
ONLY MENTIONS SYMPTOMS OR A
MEDICAL DIAGNOSIS, PROBE:
People often understand their problems in
their own way, which may be similar to or
different from how doctors describe the
problem. How would you describe your
problem?
Sometimes people have different ways of
describing their problem to their family,
friends, or others in their community. How
would you describe your problem to them?
What troubles you most about your problem?
CULTURAL PERCEPTIONS OF CAUSE, CONTEXT, AND SUPPORT
Causes
(Explanatory Model, Social Network, Older Adults)
This question indicates the meaning of the condition 4.
for the individual, which may be relevant for clinical care.
Note that individuals may identify multiple causes,
depending on the facet of the problem they are considering.
Focus on the views of members of the individual's
social network. These may be diverse and vary from
the individual's.
Why do you think this is happening to
you? What do you think are the causes of
your [PROBLEM]?
PROMPT FURTHER IF REQUIRED:
Some people may explain their problem as
the result of bad things that happen in their
life, problems with others, a physical illness, a spiritual reason, or many other
causes.
What do others in your family, your
friends, or others in your community think
is causing your [PROBLEM]?
Supplementary modules used to expand each CFI subtopic are noted in parentheses.
GUIDE TO INTERVIEWER
INSTRUCTIONS TO THE INTERVIEWER ARE
ITALICIZED.
Stressors and Supports
(Social Network, Caregivers, Psychosocial Stressors, Religion and Spirituality, Immigrants and
Refugees, Cultural Identity, Older Adults, Coping and Help Seeking)
Elicit information on the individual's life context,
focusing on resources, social supports, and resilience. May also probe other supports (e.g., from coworkers, from participation in religion or spirituality).
Focus on stressful aspects o f the individuals environment. Can also probe, e.g., relationship problems, difficulties at work or school, or
discrimination.
6. Are there any kinds of support that make
your [PROBLEM] better, such as support
from family, friends, or others?
7. Are there any kinds of stresses that make
your [PROBLEM] worse, such as difficulties with money, or family problems?
Role of Cultural Identity
(Cultural Identity, Psychosocial Stressors, Religion and Spirituality, Immigrants and Refugees,
Older Adults, Children and Adolescents)
Ask the individual to reflect on the most salient elements of his or her cultural identity. Use this
information to tailor questions 9-10 as needed.
Elicit aspects o f identity that make the problem better or worse.
Probe as needed (e.g., clinical worsening as a result
of discrimination due to migration status, race!
ethnicity, or sexual orientation).
Probe as needed (e.g., migration-related problems;
conflict across generations or due to gender roles).
Sometimes, aspects of people's background or identity can make their [PROBLEM] better or worse. By background or
identity, I mean, for example, the communities you belong to, the languages you
speak, where you or your family are from,
your race or ethnic background, your gender or sexual orientation, or your faith or
religion.
8. For you, what are the most important
aspects of your background or identity?
9. Are there any aspects of your background
or identity that make a difference to your
[PROBLEM]?
10. Are there any aspects of your background
or identity that are causing other concerns
or difficulties for you?
CULTURAL FACTORS AFFECTING SELF-COPING AND PAST HELP SEEKING
Self-Coping
(Coping and Help Seeking, Religion and Spirituality, Older Adults, Caregivers,
Psychosocial Stressors)
Clarify self-coping for the problem. 11. Sometimes people have various ways of
dealing with problems like [PROBLEM].
What have you done on your own to cope
with your [PROBLEM]?
Supplementary modules used to expand each CFI subtopic are noted in parentheses.
Past Help Seeking
(Coping and Help Seeking, Religion and Spirituality, Older Adults, Caregivers, Psychosocial
Stressors, Immigrants and Refugees, Social Network, Clinician-Patient Relationship)
Elicit various sources of help (e.g., medical care, 12. Often, people look for help from many difmental health treatment, support groups, workbased counseling, folk healing, religious or spiritual counseling, other forms of traditional or alternative healing).
Probe as needed (e.g., "What other sources of help
have you used?").
Clarify the individual's experience and regard for
previous help.
ferent sources, including different kinds of
doctors, helpers, or healers. In the past,
what kinds of treatment, help, advice, or
healing have you sought for your [PROBLEM]?
PROBE IF DOES NOT DESCRIBE USEFULNESS OF HELP RECEIVED:
What types of help or treatment were most
useful? Not useful?
Barriers
(Coping and Help Seeking, Religion and Spirituality, Older Adults, Psychosocial Stressors, Immigrants and Refugees, Social Network, Clinician-Patient Relationship)
Clarify the role of social barriers to help seeking, 13. Has anything prevented you from getting
access to care, and problems engaging in previous
treatment.
Probe details as needed (e.g., "What got in the
way?").
the help you need?
PROBE AS NEEDED:
For example, money, work or family commitments, stigma or discrimination, or lack
of services that understand your language
or background?
CULTURAL FACTORS AFFECTING CURRENT HELP SEEKING
Preferences
(Social Network, Caregivers, Religion and Spirituality, Older Adults, Coping and Help Seeking)
Clarify individual's current perceived needs and
expectations o f help, broadly defined.
Probe if individual lists only one source o f help (e.g.,
"What other kinds of help would be useful to you
at this time?").
Focus on the views of the social network regarding
help seeking.
Now let's talk some more about the help
you need.
14. What kinds of help do you think would be
most useful to you at this time for your
[PROBLEM]?
15. Are there other kinds of help that your family, friends, or other people have suggested
would be helpful for you now?
Clinician-Ραήεντ Relationship
(Clinician-Patient Relationship, Older Adults)
Elicit possible concerns about the clinic or the clinician-patient relationship, including perceived racism, language barriers, or cultural differences that
may undermine goodwill, communication, or care
delivery.
Probe details as needed (e.g., "In what way?").
Address possible barriers to care or concerns about
the clinic and the clinician-patient relationship
raised previously.
Sometimes doctors and patients misunderstand each other because they come from
different backgrounds or have different
expectations.
16. Have you been concerned about this and is
there anything that we can do to provide
you with the care you need?
Cultural Formulation Interview (CFI)—Informant Version
\
The CFI-Informant Version collects collateral information from an informant who is
knowledgeable about the clinical problems and life circumstances of the identified individual. This version can be used to supplement information obtained from the core CFI or
can be used instead of the core CFI when the individual is unable to provide information—
as might occur, for example, with children or adolescents, floridly psychotic individuals,
or persons with cognitive impairment.
Cultural Formulation Interview (CFI)— Informant Version
GUIDE TO INTERVIEWER
INSTRUCTIONS TO THE INTERVIEWER ARE
ITALICIZED.
The following questions aim to clarify key aspects of
the presenting clinical problem from the informant's point of view. This includes the problem's
meaning, potential sources of help, and expectations for services.
INTRODUCTION FOR THE INFORMANT:
I would like to understand the problems that
bring your family member/friend here so
that I can help you and him/her more effectively. I want to know about your experience
and ideas. I will ask some questions about
what is going on and how you and your family member/friend are dealing with it. There
are no right or wrong answers.
RELATIONSHIP WITH THE PATIENT
Clarify the informant's relationship with the individual and/or the individual's family.
1. How would you describe your relationship
to [INDIVIDUAL OR TO FAMILY]?
PROBE IF NOT CLEAR:
How often do you see [INDIVIDUAL]?
CULTURAL DEFINITION OF THE PROBLEM
Elicit the informant's view o f core problems and key 2.
concerns.
Focus on the informant's way of understanding the
individual's problem.
Use the term, expression, or brief description elicited
in question 1 to identify the problem in subsequent
questions (e.g., "her conflict with her son").
Ask how informant frames the problem for members 3.
of the social network.
Focus on the aspects of the problem that matter most 4.
to the informant.
What brings your family member/friend
here today?
IF INFORMANT GIVES FEW DETAILS OR
ONLY MENTIONS SYMPTOMS OR A
MEDICAL DIAGNOSIS, PROBE:
People often understand problems in their
own way, which may be similar or different from how doctors describe the problem. How would you describe
[INDIVIDUAL'S] problem?
Sometimes people have different ways of
describing the problem to family, friends,
or others in their conmiunity. How would
you describe [INDIVIDUAL'S] problem to
them?
What troubles you most about [INDIVIDUAL'S] problem?
CULTURAL PERCEPTIONS OF CAUSE, CONTEXT, AND SUPPORT
Causes
This question indicates the meaning o f the condition 5.
for the informant, which may be relevant for clinical care.
Note that informants may identify multiple causes
depending on the facet of the problem they are considering.
Why do you think this is happening to
[INDIVIDUAL]? What do you think are the
causes of his/her [PROBLEM]?
PROMPT FURTHER IF REQUIRED:
Some people may explain the problem as the
result of bad things that happen in their life,
problems with others, a physical illness, a
spiritual reason, or many other causes.
What do others in [INDIVIDUAL'S] family, his/her friends, or others in the community think is causing [INDIVIDUAL'S]
[PROBLEM]?
Supports
Elicit information on the individual's life context, 7. Are there any kinds of supports that make
Focus on the views of members of the individual's 6.
social network. These may be diverse and vary
from the informant's.
Stressors and
focusing on resources, social supports, and resilience. May also probe other supports (e.g., from coworkers, from participation in religion or spirituality).
Focus on stressful aspects of the individual's environment. Can also probe, e.g., relationship problems, difficulties at work or school, or discrimination.
8.
his/her [PROBLEM] better, such as from
family, friends, or others?
Are there any kinds of stresses that make
his/her [PROBLEM] worse, such as difficulties with money, or family problems?
Role of Cultural Identity
Ask the informant to reflect on the most salient elements of the individual's cultural identity. Use this
information to tailor questions 10-11 as needed.
Elicit aspects o f identity that make the problem better or worse.
Probe as needed (e.g., clinical worsening as a result
of discrimination due to migration status, race!
ethnicity, or sexual orientation).
Probe as needed (e.g., migration-related problems;
conflict across generations or due to gender roles).
Sometimes, aspects of people's background
or identity can make the [PROBLEM] better
or worse. By background or identity, I mean,
for example, the communities you belong to,
the languages you speak, where you or your
family are from, your race or ethnic background, your gender or sexual orientation,
and your faith or religion.
9. For you, what are the most important
aspects of [INDIVIDUAL'S] background or
identity?
10. Are there any aspects of [INDIVIDUAL'S]
background or identity that make a difference to his/her [PROBLEM]?
11. Are there any aspects of [INDIVIDUAL'S]
background or identity that are causing
other concerns or difficulties for him/her?
CULTURAL FACTORS AFFECTING SELF-COPING AND PAST HELP SEEKING
Self-Coping
Clarify individual's self-coping for the problem. 12. Sometimes people have various ways of
dealing with problems like [PROBLEM].
What has [INDIVIDUAL] done on his/her
own to cope with his/her [PROBLEM]?
Past Help Seeking
Elicit various sources o f help (e.g., medical care,
mental health treatment, support groups, workbased counseling, folk healing, religious or spiritual counseling, other alternative healing).
Probe as needed (e.g., "What other sources of help
has he/she used?").
Clarify the individual's experience and regard for
previous help.
13. Often, people also look for help from many
different sources, including different kinds
of doctors, helpers, or healers. In the past,
what kinds of treatment, help, advice, or
healing has [INDIVIDUAL] sought for his/
her [PROBLEM]?
PROBE IF DOES NOT DESCRIBE USEFULNESS OF HELP RECEIVED:
What types of help or treatment were most
useful? Not useful?
Barriers
Clarify the role of social barriers to help-seeking, 14.
access to care, and problems engaging in previous
treatment.
Probe details as needed (e.g., "What got in the
way?").
Has anything prevented [INDIVIDUAL]
from getting the help he/she needs?
PROBE AS NEEDED:
For example, money, work or family commitments, stigma or discrimination, or lack
of services that understand his/her language or background?
CULTURAL FACTORS AFFECTING CURRENT HELP SEEKING
Preferences
Clarify individual's current perceived needs and
expectations of help, broadly defined, from the
point of view of the informant.
Probe if informant lists only one source o f help (e.g.,
"What other kinds o f help would be useful to
IINDIVIDUALI at this time?").
Focus on the views o f the social network regarding
help seeking.
Now let's talk about the help [INDIVIDUAL] needs.
15. What kinds of help would be most useful to
him/her at this time for his/her [PROBLEM]?
16. Are there other kinds of help that [INDIVIDUAL'S] family, friends, or other people
have suggested would be helpful for him/
her now?
Clinician-Patient Relationship
Elicit possible concerns about the clinic or the clinician-patient relationship, including perceived racism, language barriers, or cultural differences that
may undermine goodwill, communication, or care
delivery.
Probe details as needed (e.g., "In what way?").
Address possible barriers to care or concerns about
the clinic and the clinician-patient relationship
raised previously.
Sometimes doctors and patients nüsunderstand each other because they come from
different backgrounds or have different
expectations.
17. Have you been concerned about this, and is
there anything that we can do to provide
[INDIVIDUAL] with the care he/she
needs?
Cultural Concepts of Distress
Cultural concepts of distress refers to ways that cultural groups experience, understand, and
communicate suffering, behavioral problems, or troubling thoughts and emotions. Three
main types of cultural concepts may be distinguished. Cultural syndromes are clusters of
symptoms and attributions that tend to co-occur among individuals in specific cultural
groups, communities, or contexts and that are recognized locally as coherent patterns of
experience. Cultural idioms of distress are ways of expressing distress that may not involve
specific symptoms or syndromes, but that provide collective, shared ways of experiencing
and talking about personal or social concerns. For example, everyday talk about "nerves"
or "depression" may refer to widely varying forms of suffering without mapping onto a
discrete set of symptoms, syndrome, or disorder. Cultural explanations or perceived causes
are labels, attributions, or features of an explanatory model that indicate culturally recognized meaning or etiology for symptoms, illness, or distress.
These three concepts—syndromes, idioms, and explanations—are more relevant to
clinical practice than the older formulation culture-bound syndrome. Specifically, the term
culture-bound syndrome ignores the fact that clinically important cultural differences often
involve explanations or experience of distress rather than culturally distinctive configurations of symptoms. Furthermore, the term culture-bound overemphasizes the local particularity and limited distribution of cultural concepts of distress. The current formulation
acknowledges that all forms of distress are locally shaped, including the DSM disorders.
From this perspective, many DSM diagnoses can be understood as operationalized prototypes that started out as cultural syndromes, and became widely accepted as a result of
their clinical and research utility. Across groups there remain culturally patterned differences in symptoms, ways of talking about distress, and locally perceived causes, which are
in turn associated with coping strategies and patterns of help seeking.
Cultural concepts arise from local folk or professional diagnostic systems for mental
and emotional distress, and they may also reflect the influence of biomedical concepts.
Cultural concepts have four key features in relation to the DSM-5 nosology:
• There is seldom a one-to-one correspondence of any cultural concept with a DSM diagnostic entity; the correspondence is more likely to be one-to-many in either direction.
Symptoms or behaviors that might be sorted by DSM-5 into several disorders may be
included in a single folk concept, and diverse presentations that might be classified by
DSM-5 as variants of a single disorder may be sorted into several distinct concepts by an
indigenous diagnostic system.
• Cultural concepts may apply to a wide range of severity, including presentations that
do not meet DSM criteria for any mental disorder. For example, an individual with acute
grief or a social predicament may use the same idiom of distress or display the same
cultural syndrome as another individual with more severe psychopathology.
• In common usage, the same cultural term frequently denotes more than one type of
cultural concept. A familiar example may be the concept of "depression," which may
be used to describe a syndrome (e.g., major depressive disorder), an idiom of distress
(e.g., as in the common expression "I feel depressed"), or a perceived cause (similar to
"stress").
• Like culture and DSM itself, cultural concepts may change over time in response to both
local and global influences.
Cultural concepts are important to psychiatric diagnosis for several reasons:
• To avoid misdiagnosis: Cultural variation in symptoms and in explanatory models associated with these cultural concepts may lead clinicians to misjudge the severity of a
problem or assign the wrong diagnosis (e.g., unfamiliar spiritual explanations may be
misunderstood as psychosis).
• To obtain useful clinical information: Cultural variations in symptoms and attributions may be associated with particular features of risk, resilience, and outcome.
• To improve clinical rapport and engagement: "Speaking the language of the patient,"
both linguistically and in terms of his or her dominant concepts and metaphors, can result in greater communication and satisfaction, facilitate treatment negotiation, and
lead to higher retention and adherence.
• To improve therapeutic efficacy: Culture influences the psychological mechanisms of
disorder, which need to be understood and addressed to improve clinical efficacy. For
example, culturally specific catastrophic cognitions can contribute to symptom escalation into panic attacks.
• To guide clinical research: Locally perceived connections between cultural concepts
may help identify patterns of comorbidity and underlying biological substrates.
• To clarify the cultural epidemiology: Cultural concepts of distress are not endorsed
uniformly by everyone in a given culture. Distinguishing syndromes, idioms, and explanations provides an approach for studying the distribution of cultural features of illness across settings and regions, and over time. It also suggests questions about cultural
determinants of risk, course, and outcome in clinical and community settings to enhance the evidence base of cultural research.
DSM-5 includes information on cultural concepts in order to improve the accuracy of
diagnosis and the comprehensiveness of clinical assessment. Clinical assessment of individuals presenting with these cultural concepts should determine whether they meet
DSM-5 criteria for a specified disorder or an other specified or unspecified diagnosis. Once the
disorder is diagnosed, the cultural terms and explanations should be included in case formulations; they may help clarify symptoms and etiological attributions that could otherwise be confusing. Individuals whose symptoms do not meet DSM criteria for a specific
mental disorder may still expect and require treatment; this should be assessed on a caseby-case basis. In addition to the CFI and its supplementary modules, DSM-5 contains the
following information and tools that may be useful when integrating cultural information
in clinical practice:
• Data in DSM-5 criteria and text for specific disorders: The text includes information
on cultural variations in prevalence, symptomatology, associated cultural concepts,
and other clinical aspects. It is important to emphasize that there is no one-to-one correspondence at the categorical level between DSM disorders and cultural concepts. Differential diagnosis for individuals must therefore incorporate information on cultural
variation with information elicited by the CFI.
• Other Conditions That May Be a Focus of Clinical Attention: Some of the clinical concerns identified by the CFI may correspond to V codes or Z codes—for example, acculturation problems, parent-child relational problems, or religious or spiritual problems.
• Glossary of Cultural Concepts of Distress: Located in the Appendix, this glossary provides examples of well-studied cultural concepts of distress that illustrate the relevance
of cultural information for clinical diagnosis and some of the interrelationships among
cultural syndromes, idioms of distress, and causal explanations.
Alternative DSM-5 Model
Pereonality bÎsorÉiii
ThG current approach to personality disorders appears in Section II of DSM-5,
and an alternative model developed for DSM-5 is presented here in Section III. The inclusion of both models in DSM-5 reflects the decision of the APA Board of Trustees to preserve continuity with current clinical practice, while also introducing a new approach that
aims to address numerous shortcomings of the current approach to personality disorders.
For example, the typical patient meeting criteria for a specific personality disorder frequently also meets criteria for other personality disorders. Similarly, other specified or unspecified personality disorder is often the correct (but mostly uninformative) diagnosis, in
the sense that patients do not tend to present with patterns of symptoms that correspond
with one and only one personality disorder.
In the following alternative DSM-5 model, personality disorders are characterized by
impairments in personality functioning and pathological personality traits. The specific
personality disorder diagnoses that may be derived from this model include antisocial,
avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal personality disorders. This approach also includes a diagnosis of personality disorder—trait specified
(PD-TS) that can be made when a personality disorder is considered present but the criteria for a specific disorder are not met.
General Criteria for Personality Disorder
General Criteria for Personality Disorder
The essential features of a personality disorder are
A. Moderate or greater impairment in personality (self/interpersonal) functioning.
B. One or more pathological personality traits.
C. The impairments in personality functioning and the individual’s personality trait expression are relatively inflexible and pervasive across a broad range of personal and social
situations.
D. The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time, with onsets that can be traced back to at least
adolescence or early adulthood.
E. The impairments in personality functioning and the individual’s personality trait expression are not better explained by another mental disorder.
F. The impairments in personality functioning and the individual’s personality trait expression are not solely attributable to the physiological effects of a substance or another
medical condition (e.g., severe head trauma).
G. The impairments in personality functioning and the individual’s personality trait expression are not better understood as normal for an individual’s developmental stage or sociocultural environment.
A diagnosis of a personality disorder requires two determinations: 1) an assessment of
the level of impairment in personality functioning, w^hich is needed for Criterion A, and 2)
an evaluation of pathological personality traits, which is required for Criterion B. The impairments in personality functioning and personality trait expression are relatively inflexible and pervasive across a broad range of personal and social situations (Criterion C);
relatively stable across time, with onsets that can be traced back to at least adolescence or
early adulthood (Criterion D); not better explained by another mental disorder (Criterion
E); not attributable to the effects of a substance or another medical condition (Criterion F);
and not better understood as normal for an individual's developmental stage or sociocultural environment (Criterion G). All Section III personality disorders described by criteria
sets, as well as PD-TS, meet these general criteria, by definition.
Criterion A: Levei of Personaiity Functioning
Disturbances in self and interpersonal functioning constitute the core of personality psychopathology and in this alternative diagnostic model they are evaluated on a continuum.
Self functioning involves identity and self-direction; interpersonal functioning involves
empathy and intimacy (see Table 1). The Level of Personality Functioning Scale (LPFS; see
Table 2, pp. 775-778) uses each of these elements to differentiate five levels of impairment,
ranging from little or no impairment (i.e., healthy, adaptive functioning; Level 0) to some
(Level 1), moderate (Level 2), severe (Level 3), and extreme (Level 4) impairment.
TABLE 1 Elements of personality functioning
"selfi ^
1. Identity: Experience of oneself as unique, with clear boundaries between self and others; stability of self-esteem and accuracy of self-appraisal; capacity for, and ability to regulate, a
range of emotional experience.
2. Self-direction: Pursuit of coherent and meaningful short-term and life goals; utilization of
constructive and prosocial internal standards of behavior; ability to self-reflect productively.
Interpersonal:
1. Empathy: Comprehension and appreciation of others' experiences and motivations; tolerance
of differing perspectives; understanding the effects of one's own behavior on others.
2. Intim acy: Depth and duration of connection with others; desire and capacity for closeness;
mutuality of regard reflected in interpersonal behavior.
Impairment in personality functioning predicts the presence of a personality disorder,
and the severity of impairment predicts whether an individual has more than one personality disorder or one of the more typically severe personality disorders. A moderate level
of impairment in personality functioning is required for the diagnosis of a personality disorder; this threshold is based on empirical evidence that the moderate level of impairment
maximizes the ability of clinicians to accurately and efficiently identify personality disorder pathology.
Criterion B: Pathoiogicai Personaiity Traits
Pathological personality traits are organized into five broad domains: Negative Affectivity. Detachment, Antagonism, Disinhibition, and Psychoticism. Within the five broad trait
domains are 25 specific trait facets that were developed initially from a review of existing
trait models and subsequently through iterative research with samples of persons who
sought mental health services. The full trait taxonomy is presented in Table 3 (see pp. 779
781). The B criteria for the specific personality disorders comprise subsets of the 25 trait
facets, based on meta-analytic reviews and empirical data on the relationships of the traits
to DSM-IV personality disorder diagnoses.
Criteria C and D: Pervasiveness and Stability
Impairments in personality functioning and pathological personality traits are relatively pervasive across a range of personal and social contexts, as personality is defined as a pattern of
perceiving, relating to, and thinking about the environment and oneself. The term relatively
reflects the fact that all except the most extremely pathological personalities show some degree of adaptability. The pattern in personality disorders is maladaptive and relatively inflexible, which leads to disabilities in social, occupational, or other important pursuits, as
individuals are unable to modify their thinking or behavior, even in the face of evidence that
their approach is not working. The impairments in functioning and personality traits are also
relatively stable. Personality traits—the dispositions to behave or feel in certain ways—are
more stable than the symptomatic expressions of these dispositions, but personality traits can
also change. Impairments in personality functioning are more stable than symptoms.
Criteria E, F, and G: Alternative Explanations for
Personality Pathology (Differential Diagnosis)
On some occasions, what appears to be a personality disorder may be better explained by
another mental disorder, the effects of a substance or another medical condition, or a normal developmental stage (e.g., adolescence, late life) or the individual's sociocultural environment. When another mental disorder is present, the diagnosis of a personality
disorder is not made, if the manifestations of the personality disorder clearly are an expression of the other mental disorder (e.g., if features of schizotypal personality disorder
are present only in the context of schizophrenia). On the other hand, personality disorders
can be accurately diagnosed in the presence of another mental disorder, such as major depressive disorder, and patients with other mental disorders should be assessed for comorbid personality disorders because personality disorders often impact the course of other
mental disorders. Therefore, it is always appropriate to assess personality functioning and
pathological personality traits to provide a context for other psychopathology.
Specific Personality Disorders
Section III includes diagnostic criteria for antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal personality disorders. Each personality disorder is
defined by typical impairments in personality functioning (Criterion A) and characteristic
pathological personality traits (Criterion B):
• Typical features of antisocial personality disorder are a failure to conform to lawful
and ethical behavior, and an egocentric, callous lack of concern for others, accompanied
by deceitfulness, irresponsibility, manipulativeness, and/or risk taking.
• Typical features of avoidant personality disorder are avoidance of social situations and
inhibition in interpersonal relationships related to feelings of ineptitude and inadequacy, anxious preoccupation with negative evaluation and rejection, and fears of ridicule or embarrassment.
• Typical features of borderline personality disorder are instability of self-image, personal goals, interpersonal relationships, and affects, accompanied by impulsivity, risk
taking, and/or hostility.
• Typical features of narcissistic personality disorder are variable and vulnerable selfesteem, with attempts at regulation through attention and approval seeking, and either
overt or covert grandiosity.
• Typical features of obsessive-compulsive personality disorder are difficulties in establishing and sustaining close relationships, associated with rigid perfectionism, inflexibility, and restricted emotional expression.
• Typical features of schizotypal personality disorder are impairments in the capacity
for social and close relationships, and eccentricities in cognition, perception, and behavior that are associated with distorted self-image and incoherent personal goals and accompanied by suspiciousness and restricted emotional expression.
The A and B criteria for the six specific personality disorders and for PD-TS follow. All
personality disorders also meet criteria C through G of the General Criteria for Personality
Disorder.
Antisocial Personality Disorder
Typical features of antisocial personality disorder are a failure to conform to lawful and
ethical behavior, and an egocentric, callous lack of concern for others, accompanied by deceitfulness, irresponsibility, manipulativeness, and/or risk taking. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, as described below,
along with specific maladaptive traits in the domains of Antagonism and Disinhibition.
Proposed Diagnostic Criteria
A. Moderate or greater impairment in personality functioning, manifested by characteristic
difficulties in two or more of the following four areas:
1. Identity: Egocentrism; self-esteem derived from personal gain, power, or pleasure.
2. Self-direction: Goal setting based on personal gratification; absence of prosocial
internal standards, associated with failure to conform to lawful or culturally normative ethical behavior.
3. Empathy: Lack of concern for feelings, needs, or suffering of others; lack of remorse after hurting or mistreating another.
4. Intimacy: Incapacity for mutually intimate relationships, as exploitation is a primary
means of relating to others, including by deceit and coercion; use of dominance or
intimidation to control others.
B. Six or more of the following seven pathological personality traits:
1. Manipulativeness (an aspect of Antagonism): Frequent use of subterfuge to influence or control others; use of seduction, charm, glibness, or ingratiation to
achieve one’s ends.
2. Callousness (an aspect of Antagonism): Lack of concern for feelings or problems
of others; lack of guilt or remorse about the negative or harmful effects of one’s actions on others; aggression; sadism.
3. Deceitfulness (an aspect of Antagonism): Dishonesty and fraudulence; misrepresentation of self; embellishment or fabrication when relating events.
4. Hostility (an aspect of Antagonism): Persistent or frequent angry feelings; anger or
irritability in response to minor slights and insults; mean, nasty, or vengeful behavior.
5. Risk taking (an aspect of Disinliibition): Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard for consequences;
boredom proneness and thoughtless initiation of activities to counter boredom; lack of
concern for one’s limitations and denial of the reality of personal danger.
6. Impulsivity (an aspect of Disinhibition): Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing and following plans.
7. Irresponsibility (an aspect of Disinhibition); Disregard for—and failure to honorfinancial ^nd other obligations or commitments; lack of respect for—and lack of follow-through on—agreements and promises.
Note. The individual is at least 18 years of age.
Specify if:
With psychopathic features.
Specifiers. A distinct variant often termed psychopathy (or "primary" psychopathy) is
marked by a lack of anxiety or fear and by a bold inteφersonal style that may mask maladaptive behaviors (e.g., fraudulence). This psychopathic variant is characterized by low
levels of anxiousness (Negative Affectivity domain) and withdrawal (Detachment domain) and high levels of attention seeking (Antagonism domain). High attention seeking
and low withdrawal capture the social potency (assertive/dominant) component of psychopathy, whereas low anxiousness captures the stress immunity (emotional stability/resilience) component.
In addition to psychopathic features, trait and personality functioning specifiers may be
used to record other personality features that may be present in antisocial personality disorder but are not required for the diagnosis. For example, traits of Negative Affectivity (e.g.,
anxiousness), are not diagnostic criteria for antisocial personality disorder (see Criterion B)
but can be specified when appropriate. Furthermore, although moderate or greater impairment in personality functioning is required for the diagnosis of antisocial personality disorder (Criterion A), the level of personality functioning can also be specified.
Avoidant Personality Disorder
Typical features of avoidant personality disorder are avoidance of social situations and inhibition in interpersonal relationships related to feelings of ineptitude and inadequacy,
anxious preoccupation with negative evaluation and rejection, and fears of ridicule or embarrassment. Characteristic difficulties are apparent in identity, self-direction, empathy,
and/or intimacy, as described below, along with specific maladaptive traits in the domains of Negative Affectivity and Detachment.
Proposed Diagnostic Criteria
A. Moderate or greater impairment in personality functioning, manifest by characteristic
difficulties in two or more of the following four areas:
1. Identity: Low self-esteem associated with self-appraisal as socially inept, personally unappealing, or inferior; excessive feelings of shame.
2. Self-direction: Unrealistic standards for behavior associated with reluctance to
pursue goals, take personal risks, or engage in new activities involving inteφersonal contact.
3. Empathy: Preoccupation with, and sensitivity to, criticism or rejection, associated
with distorted inference of others’ perspectives as negative.
4. Intimacy: Reluctance to get involved with people unless being certain of being
liked: diminished mutuality within intimate relationships because of fear of being
shamed or ridiculed.
B. Three or more of the following four pathological personality traits, one of which must
be (1) Anxiousness:
1. Anxiousness (an aspect of Negative Affectivity): Intense feelings of nervousness, tenseness, or panic, often in reaction to social situations: worry about the
negative effects of past unpleasant experiences and future negative possibilities;
feeling fearful, apprehensive, or threatened by uncertainty; fears of embarrassment.
2. Withdrawal (an aspect of Detachment); Reticence in social situations; avoidance
of social contacts and activity; lack of initiation of social contact.
3. Anhedonia (an aspect of Detachment): Lack of enjoyment from, engagement in,
or energy for life’s experiences; deficits in the capacity to feel pleasure or take interest in things.
4. Intimacy avoidance (an aspect of Detachment); Avoidance of close or romantic
relationships, interpersonal attachments, and intimate sexual relationships.
Specifiers. Considerable heterogeneity in the form of additional personality traits is
found among individuals diagnosed with avoidant personality disorder. Trait and level of
personality functioning specifiers can be used to record additional personality features
that may be present in avoidant personality disorder. For example, other Negative Affectivity traits (e.g., depressivity, separation insecurity, submissiveness, suspiciousness, hostility) are not diagnostic criteria for avoidant personality disorder (see Criterion B) but can
be specified when appropriate. Furthermore, although moderate or greater impairment in
personality functioning is required for the diagnosis of avoidant personality disorder (Criterion A), the level of personality functioning also can be specified.
Borderline Personality Disorder
Typical features of borderline personality disorder are instability of self-image, personal
goals, interpersonal relationships, and affects, accompanied by impulsivity, risk taking,
and/or hostility. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, as described below, along with specific maladaptive traits in the domain of Negative Affectivity, and also Antagonism and/or Disinhibition.
Proposed Diagnostic Criteria
A. Moderate or greater impairment in personality functioning, manifested by characteristic
difficulties in two or more of the following four areas:
1. Identity: Markedly impoverished, poorly developed, or unstable self-image, often
associated with excessive self-criticism; chronic feelings of emptiness; dissociative
states under stress.
2. Self-direction: Instability in goals, aspirations, values, or career plans.
3. Empathy: Compromised ability to recognize the feelings and needs of others associated with inteφersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities.
4. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust,
neediness, and anxious preoccupation with real or imagined abandonment; close
relationships often viewed in extremes of idealization and devaluation and alternating between overinvolvement and withdrawal.
B. Four or more of the following seven pathological personality traits, at least one of which
must be (5) Impulsivity, (6) Risk taking, or (7) Hostility:
1. Emotional lability (an aspect of Negative Affectivity): Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense,
and/or out of proportion to events and circumstances.
2. Anxiousness (an aspect of Negative Affectivity): Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about
the negative effects of past unpleasant experiences and future negative possibili-
ties; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling
apart or Ipsing control.
3. Separation insecurity (an aspect of Negative Affectivity): Fears of rejection by—
and/or separation from—significant others, associated with fears of excessive dependency and complete loss of autonomy.
4. Depressivity (an aspect of Negative Affectivity): Frequent feelings of being down,
miserable, and/or hopeless; difficulty recovering from such moods; pessimism
about the future; pervasive shame; feelings of inferior self-worth; thoughts of suicide and suicidal behavior.
5. Impulsivity (an aspect of Disiniiibition): Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency
and self-harming behavior under emotional distress.
6. taking (an aspect of Disiniiibition): Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for one’s limitations and denial of the reality of personal
danger.
7. Hostility (an aspect of Antagonism): Persistent or frequent angry feelings; anger
or irritability in response to minor slights and insults.
Specifiers. Trait and level of personality functioning specifiers may be used to record additional personality features that may be present in borderline personality disorder but are
not required for the diagnosis. For example, traits of Psychoticism (e.g., cognitive and perceptual dysregulation) are not diagnostic criteria for borderline personality disorder (see
Criterion B) but can be specified when appropriate. Furthermore, although moderate or
greater impairment in personality functioning is required for the diagnosis of borderline
personality disorder (Criterion A), the level of personality functioning can also be specified.
Narcissistic Personaiity Disorder
Typical features of narcissistic personality disorder are variable and vulnerable self-esteem,
with attempts at regulation through attention and approval seeking, and either overt or
covert grandiosity. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, as described below, along with specific maladaptive traits in the
domain of Antagonism.
Proposed Diagnostic Criteria
A. Moderate or greater impairment in personality functioning, manifested by characteristic
difficulties in two or more of the following four areas:
1. Identity: Excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal inflated or deflated, or vacillating between extremes;
emotional regulation mirrors fluctuations in self-esteem.
2. Self-direction: Goal setting based on gaining approval from others; personal standards unreasonably high in order to see oneself as exceptional, or too low based
on a sense of entitlement; often unaware of own motivations.
3. Empathy: Impaired ability to recognize or identify with the feelings and needs of
others; excessively attuned to reactions of others, but only if perceived as relevant
to self; over- or underestimate of own effect on others.
4. Intimacy: Relationships largely superficial and exist to serve self-esteem regulation; mutuality constrained by little genuine interest in others’ experiences and predominance of a need for personal gain.
B. Both of the following pathological personality traits:
1. Grandiosity (an aspect of Antagonism); Feelings of entitlement, either overt or covert; self-centeredness; firmly holding to the belief that one is better than others;
condescension toward others.
2. Attention seeldng (an aspect of Antagonism): Excessive attempts to attract and
be the focus of the attention of others; admiration seeking.
Specifiers. Trait and personality functioning specifiers may be used to record additional
personality features that may be present in narcissistic personality disorder but are not required for the diagnosis. For example, other traits of Antagonism (e.g., manipulativeness, deceitfulness, callousness) are not diagnostic criteria for narcissistic personality disorder (see
Criterion B) but can be specified v^hen more pervasive antagonistic feahires (e.g., "malignant
narcissism") are present. Other traits of Negative Affectivity (e.g., depressivity, anxiousness)
can be specified to record more "vulnerable" presentations. Furtiiermore, although moderate
or greater impairment in personality functioning is required for the diagnosis of narcissistic
personality disorder (Criterion A), the level of personality functioning can also be specified.
Obsessive-Compulsive Personaiity Disorder
Typical features of obsessive-compulsive personality disorder are difficulties in establishing and sustaining close relationships, associated with rigid perfectionism, inflexibility,
and restricted emotional expression. Characteristic difficulties are apparent in identity,
self-direction, empathy, and/or intimacy, as described below, along v^ith specific maladaptive traits in the domains of Negative Affectivity and/or Detachment.
Proposed Diagnostic Criteria
A. Moderate or greater impairment in personality functioning, manifested by characteristic
difficulties in two or more of the following four areas:
1. Identity: Sense of self derived predominantly from work or productivity; constricted
experience and expression of strong emotions.
2. Self-direction: Difficulty completing tasks and realizing goals, associated with rigid
and unreasonably high and inflexible internal standards of behavior; overly conscientious and moralistic attitudes.
3. Empathy: Difficulty understanding and appreciating the ideas, feelings, or behaviors of others.
4. Intimacy: Relationships seen as secondary to work and productivity; rigidity and
stubbornness negatively affect relationships with others.
B. Three or more of the following four pathological personality traits, one of which must
be (1) Rigid perfectionism:
1. Rigid perfectionism (an aspect of extreme Conscientiousness [the opposite pole
of Detachment]): Rigid insistence on everything being flawless, perfect, and without
errors or faults, including one’s own and others’ performance; sacrificing of timeliness to ensure correctness in every detail; believing that there is only one right way
to do things; difficulty changing ideas and/or viewpoint; preoccupation with details,
organization, and order.
2. Perseveration (an aspect of Negative Affectivity): Persistence at tasks long after
the behavior has ceased to be functional or effective; continuance of the same behavior despite repeated failures.
3. intimacy avoidance (an aspect of Detachment): Avoidance of close or romantic
relationships, interpersonal attachments, and intimate sexual relationships.
4. Restricted affectivity (an aspect of Detachment); Little reaction to emotionally
arousing situations; constricted emotional experience and expression; indifference
or coldness.
Specifiers. Trait and personality functioning specifiers may be used to record additional
personality features that may be present in obsessive-compulsive personality disorder but are
not required for the diagnosis. For example, other traits of Negative Affectivity (e.g., anxiousness) are not diagnostic criteria for obsessive-compulsive personality disorder (see Criterion B)
but can be specified when appropriate. Furthermore, although moderate or greater impairment in personality functioning is required for the diagnosis of obsessive-compulsive personality disorder (Criterion A), the level of personality functioning can also be specified.
Schizotypal Personality Disorder
Typical features of schizotypal personality disorder are impairments in the capacity for social and close relationships and eccentricities in cognition, perception, and behavior that
are associated with distorted self-image and incoherent personal goals and accompanied
by suspiciousness and restricted emotional expression. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, along with specific maladaptive traits in the domains of Psychoticism and Detachment.
Proposed Diagnostic Criteria
A. Moderate or greater impairment in personality functioning, manifested by characteristic
difficulties in two or more of the following four areas:
1. Identity: Confused boundaries between self and others; distorted self-concept;
emotional expression often not congruent with context or internal experience.
2. Self-direction: Unrealistic or incoherent goals; no clear set of internal standards.
3. Empathy: Pronounced difficulty understanding impact of own behaviors on others;
frequent misinterpretations of others’ motivations and behaviors.
4. Intimacy: Marked impairments in developing close relationships, associated with
mistrust and anxiety.
B. Four or more of the following six pathological personality traits:
1. Cognitive and perceptual dysregulation (an aspect of Psychoticism): Odd or
unusual thought processes; vague, circumstantial, metaphorical, overelaborate, or
stereotyped thought or speech; odd sensations in various sensory modalities.
2. Unusual beliefs and experiences (an aspect of Psychoticism): Thought content
and views of reality that are viewed by others as bizarre or idiosyncratic; unusual
experiences of reality.
3. Eccentricity (an aspect of Psychoticism): Odd, unusual, or bizarre behavior or
appearance; saying unusual or inappropriate things.
4. Restricted affectivity (an aspect of Detachment): Little reaction to emotionally
arousing situations; constricted emotional experience and expression; indifference
or coldness.
5. Withdrawal (an aspect of Detachment): Preference for being alone to being with
others; reticence in social situations; avoidance of social contacts and activity; lack
of initiation of social contact.
6. Suspiciousness (an aspect of Detachment): Expectations of—and heightened
sensitivity to—signs of interpersonal ill-intent or harm; doubts about loyalty and fidelity of others; feelings of persecution.
Specifiers. Trait and personality functioning specifiers may be used to record additional
personality features that may be present in schizotypal personality disorder but are not required for the diagnosis. For example, traits of Negative Affectivity (e.g., depressivity,
anxiousness) are not diagnostic criteria for schizotypal personality disorder (see Criterion
B) but can be specified when appropriate. Furthermore, although moderate or greater impairment in personality functioning is required for the diagnosis of schizotypal personality disorder (Criterion A), the level of personality functioning can also be specified.
Personality Disorder—Trait Specified
Proposed Diagnostic Criteria
A. Moderate or greater impairment in personality functioning, manifested by difficulties in
two or more of the following four areas:
1. Identity
2. Self-direction
3. Empathy
4. Intimacy
B. One or more pathological personality trait domains OR specific trait facets within domains, considering ALL of the following domains:
1. Negative Affectivity (vs. Emotional Stability): Frequent and intense experiences
of high levels of a wide range of negative emotions (e.g., anxiety, depression, guilt/
shame, worry, anger), and their behavioral (e.g., self-harm) and interpersonal (e.g.,
dependency) manifestations.
2. Detachment'(vs. Extraversion): Avoidance of socioemotional experience, including both withdrawal from inteφersonal interactions, ranging from casual, daily interactions to friendships to intimate relationships, as well as restricted affective
experience and expression, particularly limited hedonic capacity.
3. Antagonism (vs. Agreeableness): Behaviors that put the individual at odds with
other people, including an exaggerated sense of self-importance and a concomitant expectation of special treatment, as well as a callous antipathy toward others,
encompassing both unawareness of others’ needs and feelings, and a readiness
to use others in the service of self-enhancement.
4. Disinfiibition (vs. Conscientiousness): Orientation toward immediate gratification,
leading to impulsive behavior driven by current thoughts, feelings, and external
stimuli, without regard for past learning or consideration of future consequences.
5. Psychoticism (vs. Lucidity): Exhibiting a wide range of culturally incongruent odd,
eccentric, or unusual behaviors and cognitions, including both process (e.g., perception, dissociation) and content (e.g., beliefs).
Subtypes. Because personality features vary continuously along multiple trait dimensions, a comprehensive set of potential expressions of PD-TS can be represented by DBMS's dimensional model of maladaptive personality trait variants (see Table 3, pp. 779-781).
Thus, subtypes are unnecessary for PD-TS, and instead, the descriptive elements that constitute personality are provided, arranged in an empirically based model. This arrangement allows clinicians to tailor the description of each individual's personality disorder
profile, considering all five broad domains of personality trait variation and drawing on
the descriptive features of these domains as needed to characterize the individual.
Specifiers, The specific personality features of individuals are always recorded in evaluating Criterion Ç, so the combination of personality features characterizing an individual
directly constitutes the specifiers in each case. For example, two individuals who are both
characterized by emotional lability, hostility, and depressivity may differ such that the
first individual is characterized additionally by callousness, whereas the second is not.
Personality Disorder Sooring Algorithms
The requirement for any two of the four A criteria for each of the six personality disorders
was based on maximizing the relationship of these criteria to their corresponding personality disorder. Diagnostic thresholds for the B criteria were also set empirically to miiümize
change in prevalence of the disorders from DSM-IV and overlap with other personality
disorders, and to maximize relationships with functional impairment. The resulting diagnostic criteria sets represent clinically useful personality disorders with high fidelity, in
terms of core impairments in personality functioning of varying degrees of severity and
constellations of pathological personality traits.
Personality Disorder Diagnosis
Individuals who have a pattern of impairment in personality functioning and maladaptive
traits that matches one of the six defined personality disorders should be diagnosed with
that personality disorder. If an individual also has one or even several prominent traits that
may have clinical relevance in addition to those required for the diagnosis (e.g., see narcissistic personality disorder), the option exists for these to be noted as specifiers. Individuals
whose personality functioning or trait pattern is substantially different from that of any of
the six specific personality disorders should be diagnosed with PD-TS. The individual may
not meet the required number of A or B criteria and, thus, have a subthreshold presentation
of a personality disorder. The individual may have a mix of features of personality disorder
types or some features that are less characteristic of a type and more accurately considered
a mixed or atypical presentation. The specific level of impairment in personality functioning and the pathological personality traits that characterize the individual's personality can
be specified for PD-TS, using the Level of Personality Functioning Scale (Table 2) and the
pathological trait taxonomy (Table 3). The current diagnoses of paranoid, schizoid, histrionic, and dependent personality disorders are represented also by the diagnosis of PD-TS;
these are defined by moderate or greater impairment in personality functioning and can be
specified by the relevant pathological personality trait combinations.
Level of Personality Functioning
Like most human tendencies, personality functioning is distributed on a continuum. Central to functioning and adaptation are individuals' characteristic ways of thinking about
and understanding themselves and their interactions with others. An optimally functioning individual has a complex, fully elaborated, and well-integrated psychological world
that includes a mostly positive, volitional, and adaptive self-concept; a rich, broad, and appropriately regulated emotional life; and the capacity to behave as a productive member of
society with reciprocal and fulfilling interpersonal relationships. At the opposite end of
the continuum, an individual with severe personality pathology has an impoverished, disorgarüzed, and/or conflicted psychological world that includes a weak, unclear, and maladaptive self-concept; a propensity to negative, dysregulated emotions; and a deficient
capacity for adaptive interpersonal functioning and social behavior.
S e lf - and I n t e r p e r s o n a l Functioning
Dimensional Definition
Generalized severity may be the most important single predictor of concurrent and prospective dysfunction in assessing personality psychopathology. Personality disorders are
optimally characterized by a generalized personality severity continuum with additional
specification of stylistic elements, derived from personality disorder symptom constellations and personality traits. At the same time, the core of personality psychopathology is
impairment in ideas and feelings regarding self and interpersonal relationships; this notion is consistent with multiple theories of personality disorder and their research bases. The
components of the Level of Personality Functioning Scale—identity, self-direction, empathy, and intimacy (see Table 1)—are particularly central in describing a personality functioning continuum.
Mental representations of the self and interpersonal relationships are reciprocally influential and inextricably tied, affect the nature of interaction with mental health professionals, and can have a significant impact on both treatment efficacy and outcome,
underscoring the importance of assessing an individual's characteristic self-concept as
well as views of other people and relationships. Although the degree of disturbance in the
self and interpersonal functioning is continuously distributed, it is useful to consider the
level of impairment in functioning for clinical characterization and for treatment planning
and prognosis.
Rating Levei of Personaiity Functioning
To use the Level of Personality Functioning Scale (LPFS), the clinician selects the level that
most closely captures the individual's current overall level of impairment in personality functioning. The rating is necessary for the diagnosis of a personality disorder (moderate or greater
impairment) and can be used to specify the severity of impairment present for an individual
with any personality disorder at a given point in time. The LPFS may also be used as a global
indicator of personality functioning without specification of a personality disorder diagnosis,
or in the event that personality impairment is subthreshold for a disorder diagnosis.
Personality Traits
Definition and Description
Criterion B in the alternative model involves assessments of personality traits that are
grouped into five domains. A personality trait is a tendency to feel, perceive, behave, and
think in relatively consistent ways across time and across situations in which the trait may
manifest. For example, individuals with a high level of the personality trait of anxiousness
would tend to feel anxious readily, including in circumstances in which most people
would be calm and relaxed. Individuals high in trait anxiousness also would perceive situations to be anxiety-provoking more frequently than would individuals with lower levels of this trait, and those high in the trait would tend to behave so as to avoid situations that
they think would make them anxious. They would thereby tend to think about the world as
more anxiety provoking than other people.
Importantly, individuals high in trait anxiousness would not necessarily be anxious at
all times and in all situations. Individuals' trait levels also can and do change throughout
life. Some changes are very general and reflect maturation (e.g., teenagers generally are
higher on trait impulsivity than are older adults), whereas other changes reflect individuals' life experiences.
Dimensionality of peiOonality traits. All individuals can be located on the spectrum of
trait dimensions; that is, personality traits apply to everyone in different degrees rather
than being present versus absent. Moreover, personality traits, including those identified
specifically in tl^e Section III model, exist on a spectrum v^ith two opposing poles. For example, the opposite of the trait of callousness is the tendency to be empathie and kindhearted, even in circumstances in w^hich most persons would not feel that way. Hence, although in Section III this trait is labeled callousness, because that pole of the dimension is
the primary focus, it could be described in full as callousness versus kind-heartedness. Moreover, its opposite pole can be recognized and may not be adaptive in all circumstances
(e.g., individuals who, due to extreme kind-heartedness, repeatedly allow themselves to
be taken advantage of by unscrupulous others).
Hierarchical structure of personality. Some trait terms are quite specific (e.g., "talkative")
and describe a narrow range of behaviors, whereas others are quite broad (e.g.. Detachment) and characterize a wide range of behavioral propensities. Broad trait dimensions
are called domains, and specific trait dimensions are called facets. Personality trait domains
comprise a spectrum of more specific personality facets that tend to occur together. For example, withdrawal and anhedonia are specific trait facets in the trait domain of Detachment.
Despite some cross-cultural variation in personality trait facets, the broad domains they
collectively comprise are relatively consistent across cultures.
The Personality Trait IVlodel
The Section III personality trait system includes five broad domains of personality trait
variation—Negative Affectivity (vs. Emotional Stability), Detachment (vs. Extraversion),
Antagonism (vs. Agreeableness), Disinhibition (vs. Conscientiousness), and Psychoticism
(vs. Lucidity)—comprising 25 specific personality trait facets. Table 3 provides definitions
of all personality domains and facets. These five broad domains are maladaptive variants
of the five domains of the extensively validated and replicated personality model known
as the "Big Five", or Five Factor Model of personality (FFM), and are also similar to the domains of the Personality Psychopathology Five (PSY-5). The specific 25 facets represent a
list of personality facets chosen for their clinical relevance.
Although the Trait Model focuses on personality traits associated with psychopathology, there are healthy, adaptive, and resilient personality traits identified as the polar
opposites of these traits, as noted in the parentheses above (i.e.. Emotional Stability, Extra version, Agreeableness, Conscientiousness, and Lucidity). Their presence can greatly
mitigate the effects of mental disorders and facilitate coping and recovery from traumatic
injuries and other medical illness.
Distinguishing Traits, Symptoms, and Specific Behaviors
Although traits are by no means immutable and do change throughout the life span, they
show relative consistency compared with symptoms and specific behaviors. For example,
a person may behave impulsively at a specific time for a specific reason (e.g., a person who
is rarely impulsive suddenly decides to spend a great deal of money on a particular item
because of an unusual opportunity to purchase something of unique value), but it is only
when behaviors aggregate across time and circumstance, such that a pattern of behavior
distinguishes between individuals, that they reflect traits. Nevertheless, it is important to
recognize, for example, that even people who are impulsive are not acting impulsively all
of the time. A trait is a tendency or disposition toward specific behaviors; a specific behavior is an instance or manifestation of a trait.
Similarly, traits are distinguished from most symptoms because symptoms tend to
wax and wane, whereas traits are relatively more stable. For example, individuals with
higher levels of depressivity have a greater likelihood of experiencing discrete episodes of a
depressive disorder and of showing the symptoms of these disorders, such difficulty concentrating. However, even patients who have a trait propensity to depressivity typically cycle through distinguishable episodes of mood disturbance, and specific symptoms such as
difficulty concentrating tend to wax and wane in concert with specific episodes, so they do
not form part of the trait definition. Importantly, however, symptoms and traits are both
amenable to intervention, and many interventions targeted at symptoms can affect the
longer term patterns of personality functioning that are captured by personality traits.
Assessment of the DSM-5 Section III
Personality Trait Model
The clinical utility of the Section ΙΠ multidimensional personality trait model lies in its ability
to focus attention on multiple relevant areas of personality variation in each individual patient.
Rather than focusing attention on the identification of one and only one optimal diagnostic
label, clinical application of the Section III personality trait model involves reviewing all five
broad personality domains portrayed in Table 3. The clinical approach to personality is similar
to the well-known review of systems in clinical medicine. For example, an individual's presenting complaint may focus on a specific neurological symptom, yet during an initial
evaluation clinicians still systematically review functioning in all relevant systems (e.g., cardiovascular, respiratory, gastrointestinal), lest an important area of diminished functioning
and corresponding opportunity for effective intervention be missed.
Clinical use of the Section III personality trait model proceeds similarly. An initial inquiry reviews all five broad domains of personality. This systematic review is facilitated
by the use of formal psychometric instruments designed to measure specific facets and domains of personality. For example, the personality trait model is operationalized in the
Personality Inventory for DSM-5 (PID-5), which can be completed in its self-report form by
patients and in its informant-report form by those who know the patient well (e.g., a
spouse). A detailed clinical assessment would involve collection of both patient- and informant-report data on all 25 facets of the personality trait model. However, if this is not
possible, due to time or other constraints, assessment focused at the five-domain level is an
acceptable clinical option when only a general (vs. detailed) portrait of a patient's personality is needed (see Criterion B of PD-TS). However, if personality-based problems are the
focus of treatment, then it will be important to assess individuals' trait facets as well as domains.
Because personality traits are continuously distributed in the population, an approach
to making the judgment that a specific trait is elevated (and therefore is present for diagnostic purposes) could involve comparing individuals' personality trait levels with population norms and/or clinical judgment. If a trait is elevated—that is, formal psychometric
testing and/or interview data support the clinical judgment of elevation—then it is considered as contributing to meeting Criterion B of Section III personality disorders.
Clinical Utility of the Multidimensional Personality
Functioning and Trait Model
Disorder and trait constructs each add value to the other in predicting important antecedent (e.g., family history, history of child abuse), concurrent (e.g., functional impairment,
medication use), and predictive (e.g., hospitalization, suicide attempts) variables. DSM-5
impairments in personality functioning and pathological personality traits each contribute independently to clinical decisions about degree of disability; risks for self-harm, violence, and criminality; recommended treatment type and intensity; and prognosis—all
important aspects of the utility of psychiatric diagnoses. Notably, knowing the level of an
individual's personality functioning and his or her pathological trait profile also provides
the clinician with a rich base of information and is valuable in treatment planning and in
predicting the course and outcome of many mental disorders in addition to personality
disorders. Therefore, assessment of personality functioning and pathological personality
traits may be relevant whether an individual has a personality disorder or not.
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TABLE 3 Dc^finitions of DSM-5 personality disorder trait domains
and facets
DOMAINS (Polar Opposites)
and Facets Definitions
NEGATIVEAFFECTIVITY
(vs. Emotional Stability)
Emotional lability
Anxiousness
Separation insecurity
Submissiveness
Hostility
Perseveration
Depressivity
Suspiciousness
Restricted affectivity
(lack of)
DETACHMENT
(vs. Extraversion)
Withdrawal
Intimacy avoidance
Anhedonia
Depressivity
Restricted affectivity
Suspiciousness
Frequent and intense experiences of high levels of a wide range of
negative emotions (e.g., anxiety, depression, guilt/ shame, worry,
anger) and their behavioral (e.g., self-harm) and interpersonal (e.g.,
dependency) manifestations.
Instability of emotional experiences and mood; emotions that are
easily aroused, intense, and/or out of proportion to events and circumstances.
Feelings of nervousness, tenseness, or panic in reaction to diverse situations; frequent worry about the negative effects of past unpleasant
experiences and future negative possibilities; feeling fearful and
apprehensive about uncertainty; expecting the worst to happen.
Fears of being alone due to rejection by—and/or separation from—
significant others, based in a lack of confidence in one's ability to
care for oneself, both physically and emotionally.
Adaptation of one's behavior to the actual or perceived interests and
desires of others even when doing so is antithetical to one's own
interests, needs, or desires.
Persistent or frequent angry feelings; anger or irritability in response
to minor slights and insults; mean, nasty, or vengeful behavior. See
also Antagonism.
Persistence at tasks or in a particular way of doing things long after the
behavior has ceased to be functional or effective; continuance of the
same behavior despite repeated failures or clear reasons for stopping.
See Detachment.
See Detachment.
The lack o/this facet characterizes low levels of Negative Affectivity.
See Detachment for definition of this facet.
Avoidance of socioemotional experience, including both withdrawal
from interpersonal interactions (ranging from casual, daily interactions to friendships to intimate relationships) and restricted affective
experience and expression, particularly limited hedonic capacity.
Preference for being alone to being with others; reticence in social situations; avoidance of social contacts and activity; lack of initiation
of social contact.
Avoidance of close or romantic relationships, interpersonal attachments, and intimate sexual relationships.
Lack of enjoyment from, engagement in, or energy for life's experiences;
deficits in the capacity to feel pleasure and take interest in things.
Feelings of being down, nüserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive
shame and/or guilt; feelings of inferior self-worth; thoughts of suicide and suicidal behavior.
Little reaction to emotionally arousing situations; constricted emotional experience and expression; indifference and aloofness in normatively engaging situations.
Expectations of—and sensitivity to—signs of inteφersonal illintent or harm; doubts about loyalty and fidelity of others; feelings
of being mistreated, used, and/or persecuted by others.
TABLE 3 Definitions of DSIVI-S personality disorder trait domains
and facets (continued)
DOMAINS (Polar Opposites)
and Facets Definitions
ANTAGONISM (vs.
Agreeableness)
Manipulativeness
Deceitfulness
Grandiosity
Attention seeking
Callousness
Hostility
DISINHIBITION
(vs. Conscientiousness)
Irresponsibility
Impulsivity
Distractibility
Risk taking
Rigid perfectionism (lack of)
Behaviors that put the individual at odds with other people, including an exaggerated sense of self-importance and a concomitant
expectation of special treatment, as well as a callous antipathy
toward others, encompassing both an unawareness of others'
needs and feelings and a readiness to use others in the service of
self-enhancement.
Use of subterfuge to influence or control others; use of seduction,
charm, glibness, or ingratiation to achieve one's ends.
Dishonesty and fraudulence; misrepresentation of self; embellishment or fabrication when relating events.
Believing that one is superior to others and deserves special treatment; self-centeredness; feelings of entitlement; condescension
toward others.
Engaging in behavior designed to attract notice and to make oneself
the focus of others' attention and admiration.
Lack of concern for the feelings or problems of others; lack of guilt
or remorse about the negative or harmful effects of one's actions
on others.
See Negative Affectivity.
Orientation toward immediate gratification, leading to impulsive
behavior driven by current thoughts, feelings, and external stimuli, without regard for past learning or consideration of future
consequences.
Disregard for—and failure to honor—financial and other obligations or commitments; lack of respect for—and lack of followthrough on—agreements and promises; carelessness with others'
property.
Acting on the spur of the moment in response to immediate stimuli;
acting on a momentary basis without a plan or consideration of
outcomes; difficulty establishing and following plans; a sense of
urgency and self-harming behavior under emotional distress.
Difficulty concentrating and focusing on tasks; attention is easily
diverted by extraneous stimuli; difficulty maintaining goalfocused behavior, including both planning and completing tasks.
Engagement in dangerous, risky, and potentially self-damaging
activities, unnecessarily and without regard to consequences; lack
of concern for one's limitations and denial of the reality of personal danger; reckless pursuit of goals regardless of the level of
risk involved.
Rigid insistence on everything being flawless, perfect, and without
errors or faults, including one's own and others' performance; sacrificing of timeliness to ensure correctness in every detail; believing that there is only one right way to do things; difficulty
changing ideas and/or viewpoint; preoccupation with details,
organization, and order. The lack o/this facet characterizes low
levels of Disinhibition.
TABLE 3 Definitions of DSM-5 personality disorder trait domains
and facets (continued)
DOMAINS (Polar Opposites)
and Facets Definitions
PSYCHOTICISM
(vs. Lucidity)
Unusual beliefs and
experiences
Eccentricity
Cognitive and perceptual
dysregulation
Exhibiting a wide range of culturally incongruent odd, eccentric, or
unusual behaviors and cognitions, including both process (e.g.,
perception, dissociation) and content (e.g., beliefs).
Belief that one has unusual abilities, such as mind reading, telekinesis, thought-action fusion, unusual experiences of reality, including hallucination-like experiences.
Odd, unusual, or bizarre behavior, appearance, and/or speech;
having strange and unpredictable thoughts; saying unusual or
inappropriate things.
Odd or unusual thought processes and experiences, including
depersonalization, derealization, and dissociative experiences;
mixed sleep-wake state experiences; thought-control experiences.
P r o p o s e d C riteriâ sets are presented for conditions on which future research is encouraged. The specific items, thresholds, and durations contained in these research criteria sets were set by expert consensus—informed by literature review, data reanalysis, and
field trial results, where available—and are intended to provide a common language for
researchers and clinicians who are interested in studying these disorders. It is hoped that
such research will allow the field to better understand these conditions and will inform
decisions about possible placement in forthcoming editions of DSM. The DSM-5 Task
Force and Work Groups subjected each of these proposed criteria sets to a careful empirical review and invited wide commentary from the field as well as from the general public.
The Task Force determined that there was insufficient evidence to warrant inclusion of
these proposals as official mental disorder diagnoses in Section II. These proposed criteria
sets are not intended fo r clinical use; only the criteHa sets and disorders in Section I I of
D S M -5 are officially recognized and can be used fo r clinical purposes.
Attenuated Psychosis Syndrome
Proposed Criteria
A. At least one of the following symptoms is present in attenuated form, with relatively intact reality testing, and is of sufficient severity or frequency to warrant clinical attention:
1. Delusions.
2. Hallucinations.
3. Disorganized speech.
B. Symptom(s) must have been present at least once per week for the past month.
C. Symptom(s) must have begun or worsened in the past year.
D. Symptom(s) is sufficiently distressing and disabling to the individual to warrant clinical
attention.
E. Symptom(s) is not better explained by another mental disorder, including a depressive
or bipolar disorder with psychotic features, and is not attributable to the physiological
effects of a substance or another medical condition.
F. Criteria for any psychotic disorder have never been met._______________________
Diagnostic Features
Attenuated psychotic symptoms, as defined in Criterion A, are psychosis-like but below the
threshold for a full psychotic disorder. Compared with psychotic disorders, the symptoms
are less severe and more transient, and insight is relatively maintained. A diagnosis of attenuated psychosis syndrome requires state psychopathology associated with functional
impairment rather than long-standing trait pathology. The psychopathology has not progressed to full psychotic severity. Attenuated psychosis syndrome is a disorder based on the
manifest pathology and impaired function and distress. Changes in experiences and behav-
iors are noted by the individual and/or others, suggesting a change in mental state (i.e., the
symptoms are of sufficient severity or frequency to warrant clinical attention) (Criterion A).
Attenuated delusions (Criterion Al) may have suspiciousness/persecutory ideational content, including persecutory ideas of reference. The individual may have a guarded, distrustful attitude. When the delusions are moderate in severity, the individual views others as
untrustworthy and may be hypervigilant or sense ill will in others. When the delusions are
severe but still within the attenuated range, the individual entertains loosely organized beliefs about danger or hostile intention, but the delusions do not have the fixed nature that is
necessary for the diagnosis of a psychotic disorder. Guarded behavior in the interview can
interfere with the ability to gather information. Reality testing and perspective can be elicited with nonconfirming evidence, but the propensity for viewing the world as hostile and
dangerous remains strong. Attenuated delusions may have grandiose content presenting as
an unrealistic sense of superior capacity. When the delusions are moderate, the individual
harbors notions of being gifted, influential, or special. When the delusions are severe, the individual has beliefs of superiority that often alienate friends and worry relatives. Thoughts
of being special may lead to unrealistic plans and investments, yet skepticism about these attitudes can be elicited with persistent questioning and confrontation.
Attenuated hallucinations (Criterion A2) include alterations in sensory perceptions,
usually auditory and/or visual. When the hallucinations are moderate, the sounds and
images are often unformed (e.g., shadows, trails, halos, murmurs, rumbling), and they are
experienced as unusual or puzzling. When the hallucinations are severe, these experiences
become more vivid and frequent (i.e., recurring illusions or hallucinations that capture attention and affect thinking and concentration). These perceptual abnormalities may disrupt behavior, but skepticism about their reality can still be induced.
Disorganized communication (Criterion A3) may manifest as odd speech (vague, metaphorical, overelaborate, stereotyped), unfocused speech (confused, muddled, too fast or too
slow, wrong words, irrelevant context, off track), or meandering speech (circumstantial, tangential). When the disorganization is moderately severe, the individual frequently gets into
irrelevant topics but responds easily to clarifying questions. Speech may be odd but understandable. At the moderately severe level, speech becomes meandering and circumstantial,
and when the disorganization is severe, the individual fails to get to the point without
external guidance (tangential). At the severe level, some thought blocking and/or loose associations may occur infrequently, especially when the individual is under pressure, but reorienting questions quickly return structure and organization to the conversation.
The individual realizes that changes in mental state and/or in relationships are taking
place. He or she maintains reasonable insight into the psychotic-like experiences and generally appreciates that altered perceptions are not real and magical ideation is not compelling. The individual must experience distress and/or impaired performance in social or role
functioning (Criterion D), and the individual or responsible others must note the changes
and express concern, such that clinical care is sought (Criterion A).
Associated Features Supporting Diagnosis
The individual may experience magical thinking, perceptual aberrations, difficulty in concentration, some disorganization in thought or behavior, excessive suspiciousness, anxiety, social withdrawal, and disruption in sleep-wake cycle. Impaired cognitive function
and negative symptoms are often observed. Neuroimaging variables distinguish cohorts
with attenuated psychosis syndrome from normal control cohorts with patterns similar to,
but less severe than, that observed in schizophrenia. However, neuroimaging data is not
diagnostic at the individual level.
Prevalence
The prevalence of attenuated psychosis syndrome is unknown. Symptoms in Criterion A
are not uncommon in the non-help-seeking population, ranging from 8%-13% for hallu
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