Psychiatry Online_DSM Library_Personality Disorders.

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 1/98

Back to table of contents Previous Chapter Next Chapter

 Full Access

Personality Disorders Edited by:

https://doi.org/10.1176/appi.books.9780890425787.x18_Personality_Disorders

This chapter begins with a general definition of personality disorder that applies to each of

the 10 specific personality disorders. A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the norms and expectations of the

individual’s culture, is pervasive and inflexible, has an onset in adolescence or early

adulthood, is stable over time, and leads to distress or impairment.

With any ongoing review process, especially one of this complexity, different viewpoints

emerge, and an effort was made to accommodate them. Thus, personality disorders are

included in both Sections II and III. The material in Section II represents an update of text

associated with the same criteria found in DSM-5 (which were carried over from DSM-IV-

TR), whereas Section III includes the proposed model for personality disorder diagnosis

and conceptualization developed by the DSM-5 Personality and Personality Disorders

The American Psychiatric Association (APA) has updated its Privacy Policy and Terms of Use, including with new information specifically addressed to individuals in the European Economic Area. As described in the Privacy Policy and Terms of Use, this website utilizes cookies, including for the purpose of offering an optimal online experience and services tailored to your preferences.

Please read the entire Privacy Policy and Terms of Use. By closing this message, browsing this website, continuing the navigation, or otherwise continuing to use the APA’s websites, you confirm that you understand and accept the terms of the Privacy Policy and Terms of Use, including the utilization of cookies.

××

 sections 

https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787
https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x17_Neurocognitive_Disorders
https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x19_Paraphilic_Disorders
https://doi.org/10.1176/appi.books.9780890425787.x18_Personality_Disorders
https://psychiatryonline.org/
https://psychiatryonline.org/privacypolicy
https://psychiatryonline.org/termsofuse
https://dsm.psychiatryonline.org/personalize/addFavoritePublication?doi=10.1176/dsm
https://dsm.psychiatryonline.org/action/showPreferences?menuTab=Alerts
https://dsm.psychiatryonline.org/
8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 2/98

Work Group. As this field evolves, it is hoped that both versions will serve clinical practice

and research initiatives, respectively.

The following personality disorders are included in this chapter.

Paranoid personality disorder is a pattern of distrust and suspiciousness such that others’ motives are interpreted as malevolent.

Schizoid personality disorder is a pattern of detachment from social

relationships and a restricted range of emotional expression.

Schizotypal personality disorder is a pattern of acute discomfort in close

relationships, cognitive or perceptual distortions, and eccentricities of behavior.

Antisocial personality disorder is a pattern of disregard for, and violation of, the

rights of others, criminality, impulsivity, and a failure to learn from experience.

Borderline personality disorder is a pattern of instability in interpersonal

relationships, self-image, and affects, and marked impulsivity.

Histrionic personality disorder is a pattern of excessive emotionality and attention seeking.

Narcissistic personality disorder is a pattern of grandiosity, need for admiration,

and lack of empathy.

Avoidant personality disorder is a pattern of social inhibition, feelings of

inadequacy, and hypersensitivity to negative evaluation.

Dependent personality disorder is a pattern of submissive and clinging behavior

related to an excessive need to be taken care of.

Obsessive-compulsive personality disorder is a pattern of preoccupation with

orderliness, perfectionism, and control.

Personality change due to another medical condition is a persistent

personality disturbance that is judged to be the direct pathophysiological consequence

of another medical condition (e.g., frontal lobe lesion).

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 3/98

Other specified personality disorder is a category provided for two situations: 1)

the individual’s personality pattern meets the general criteria for a personality

disorder, and traits of several different personality disorders are present, but the

criteria for any specific personality disorder are not met; or 2) the individual’s

personality pattern meets the general criteria for a personality disorder, but the

individual is considered to have a personality disorder that is not included in the

DSM-5 classification (e.g., passive-aggressive personality disorder). Unspecified

personality disorder is for presentations in which symptoms characteristic of a personality disorder are present but there is insufficient information to make a more

specific diagnosis.

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 obsessive-compulsive personality disorders. Individuals with these

disorders often appear anxious or fearful. It should be noted that this clustering system,

although useful in some research and educational situations, has serious limitations and

has not been consistently validated. For instance, two or more disorders from different

clusters, or traits from several of them, can often co-occur and vary in intensity and

pervasiveness.

A review of epidemiological studies from several countries found a median prevalence of

3.6% for disorders in Cluster A, 4.5% for Cluster B, 2.8% for Cluster C, and 10.5% for any

personality disorder (Huang et al. 2009; Morgan and Zimmerman 2018). Prevalence

appears to vary across countries and by ethnicity, raising questions about true cross-

cultural variation and about the impact of diverse definitions and diagnostic instruments

on prevalence assessments (McGilloway et al. 2010; Tyrer et al. 2010).

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

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 4/98

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-5 personality disorder clusters (i.e., odd-eccentric, dramatic-

emotional, and anxious-fearful) may also be viewed as dimensions representing spectra of

personality dysfunction on a continuum with 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

continue to be under active investigation. This includes research on whether the

dimensional model can clarify the cross-cultural prevalence variations seen with the

categorical model (Alarcón et al. 1998; McGilloway et al. 2010; Tyrer et al. 2010).

References: Dimensional Models for Personality Disorders

Alarcón RD, Foulks EF, Vakkur M: Personality Disorders and Culture: Clinical and

Conceptual Interactions. New York, Wiley, 1998

Huang Y, Kotov R, de Girolamo G, et al: DSM-IV personality disorders in the WHO World

Mental Health Surveys. Br J Psychiatry 195(1):46–53, 2009

McGilloway A, Hall RE, Lee T, Bhui KS: A systematic review of personality disorder, race

and ethnicity: prevalence, aetiology and treatment. BMC Psychiatry 10:33, 2010

Morgan TA, Zimmerman M: Epidemiology of personality disorders, in Handbook of

Personality Disorders: Theory, Research, and Treatment, 2nd Edition. Edited by Livesley

WJ, Larstone R. New York, Guilford, 2018, pp 173–196

Tyrer P, Mulder R, Crawford M, et al: Personality disorder: a new global perspective.

World Psychiatry 9(1):56–60, 2010

General Personality Disorder

Criteria

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 5/98

A. An enduring pattern of inner experience and behavior that deviates markedly

from the expectations of the individual’s culture. This pattern is manifested in two

(or more) of the following areas:

1. Cognition (i.e., ways of perceiving and interpreting self, other people, and

events).

2. Affectivity (i.e., the range, intensity, lability, and appropriateness of

emotional response).

3. Interpersonal functioning.

4. Impulse control.

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

and social situations.

C. The enduring pattern leads to clinically significant distress or impairment in

social, occupational, or other important areas of functioning.

D. The pattern is stable and of long duration, and its onset can be traced back at least

to adolescence or early adulthood.

E. The enduring pattern is not better 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

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 6/98

that deviates markedly from the norms and 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 long-term

patterns of functioning, and the particular personality features must be evident by early

adulthood. The personality traits that define these disorders must also be distinguished

from characteristics that emerge in response to specific situational stressors or more

transient mental states (e.g., 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.

Development 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., obsessive-

compulsive and schizotypal personality disorders).

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 7/98

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 attributable to 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 personality 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

Core aspects of personality like emotion regulation and interpersonal functioning are

influenced by culture, which also provides means of protection and assimilation and norms

for acceptance and denunciation of specific behaviors and personality traits (Ronningstam

et al. 2018). 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 migration or with the

expression of habits, customs, or religious and political values based on the individual’s

cultural background or context. Behavioral patterns that appear to be rigid and

dysfunctional aspects of personality disorder may reflect instead adaptive responses to

cultural constraints (Balaratnasingam and Janca 2017; Fang et al. 2016; Ronningstam et al.

2018; Ryder et al. 2014). For example, reliance on an abusive relationship in a small

community where divorce is proscribed may not reflect pathological dependence;

conscientious political protest that puts friends and family members at risk with authorities

or in conflict with legal norms does not necessarily reflect pathological callousness (Ryder

et al. 2014). There are marked variations in the recognition and diagnosis of personality

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 8/98

disorders across cultural, ethnic, and racialized groups (Alarcón et al. 1998; McGilloway et

al. 2010; Tyrer et al. 2010). Accuracy of diagnosis can be enhanced by attention to

culturally patterned conceptions of self and attachment, assessment biases resulting from

clinicians’ own cultural backgrounds or use of diagnostic instruments that are not normed

to the population being assessed, and the impact of social determinants such as poverty,

acculturative stress, racism, and discrimination on feelings, cognitions, and

behaviors (Iacovino et al. 2014; Raza et al. 2014; Ryder et al. 2014). 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.

Sex- and Gender-Related Diagnostic Issues

Certain personality disorders (e.g., antisocial personality disorder) are diagnosed more

frequently in men. Others (e.g., borderline, histrionic, and dependent personality

disorders) are diagnosed more frequently in women; however, in the case of borderline

personality disorder, this may be due to higher help-seeking among women. Nonetheless,

clinicians must be cautious not to overdiagnose or underdiagnose certain personality

disorders in women or in men because of social stereotypes about typical gender roles and

behaviors. There is currently insufficient evidence on differences between cis- and

transgender individuals with respect to the epidemiology or clinical presentations of

personality disorders to draw meaningful conclusions.

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 the defining

characteristics appeared before early adulthood, are typical of the individual’s long-term

functioning, and do not occur exclusively during an episode of 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

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 9/98

disorder with schizophrenia; avoidant personality disorder with social anxiety disorder)

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, because these conditions may have cross-

sectional symptom features that mimic personality traits and may make it more difficult to

evaluate retrospectively the individual’s long-term patterns of functioning.

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).

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 10/98

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.

References: General Personality Disorder

Alarcón RD, Foulks EF, Vakkur M: Personality Disorders and Culture: Clinical and

Conceptual Interactions. New York, Wiley, 1998

Balaratnasingam S, Janca A: Culture and personality disorder: a focus on indigenous

Australians. Curr Opin Psychiatry 30(1):31–35, 2017

Fang K, Friedlander M, Pieterse AL: Contributions of acculturation, enculturation,

discrimination, and personality traits to social anxiety among Chinese immigrants: a

context-specific assessment. Culture Divers Ethnic Minor Psychol 22(1):58–68, 2016

Iacovino JM, Jackson JJ, Oltmanns TF: The relative impact of socioeconomic status and

childhood trauma on Black-White differences in paranoid personality disorder symptoms.

J Abnorm Psychol 123(1):225–230, 2014

McGilloway A, Hall RE, Lee T, Bhui KS: A systematic review of personality disorder, race

and ethnicity: prevalence, aetiology and treatment. BMC Psychiatry 10:33, 2010

Raza GT, DeMarce JM, Lash SJ, Parker JD: Paranoid personality disorder in the United

States: the role of race, illicit drug use, and income. J Ethn Subst Abuse 13(3):247–257,

2014

Ronningstam EF, Keng S-L, Ridolfi ME et al. Cultural aspects in symptomatology,

assessment, and treatment of personality disorders. Curr Psychiatry Rep 20(4):22, 2018

29582187

Ryder AG, Dere J, Sun J, Chentsova-Dutton YE: The cultural shaping of personality

disorder, in APA Handbook of Multicultural Psychology. Edited by Leong FTL, Comas-

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 11/98

(F60.0)

Diaz L, Hall GCN, et al. Washington, DC, American Psychological Association, 2014, pp

307–328

Tyrer P, Mulder R, Crawford M, et al: Personality disorder: a new global perspective.

World Psychiatry 9(1):56–60, 2010

Cluster A Personality Disorders

Paranoid Personality Disorder

Diagnostic Criteria

A. A pervasive distrust and suspiciousness of others such that their motives 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.

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 12/98

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 A1). 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 coworker 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

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 13/98

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

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 hostile

aloofness. They 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 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

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 14/98

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.

Prevalence

The estimated prevalence of paranoid personality based on a probability subsample from

Part II of the National Comorbidity Survey Replication was 2.3% (Lenzenweger et al.

2007). The prevalence of paranoid personality disorder in the National Epidemiologic

Survey on Alcohol and Related Conditions was 4.4% (Grant et al. 2004). A review of six

epidemiological studies (four in the United States) found a median prevalence of 3.2%

(Morgan and Zimmerman 2018). In forensic settings, the estimated prevalence may be as

high as 23% (Ullrich et al. 2008).

Development and Course

Paranoid personality disorder may be first apparent in childhood and adolescence with

solitariness, poor peer relationships, social anxiety, underachievement in school, and

interpersonal hypersensitivity. Adolescent onset of paranoid personality disorder is

associated with a prior history of childhood maltreatment, externalizing symptoms,

bullying of peers, and adult appearance of interpersonal aggression (Johnson et al. 2000;

Natsuaki et al. 2009).

Risk and Prognostic Factors

Environmental

Exposure to social stressors such as socioeconomic inequality, marginalization, and racism

is associated with decreased trust, which in some cases is adaptive. The combination of

social stress and childhood maltreatment accounts for the increased prevalence of paranoid

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 15/98

symptoms in social groups facing racial discrimination (Iacovino et al. 2014). Both

longitudinal (Natsuaki et al. 2009) and cross-sectional studies confirm that childhood

trauma is a risk factor for paranoid personality disorder (Lee 2017).

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 (Kendler et al. 1985).

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. Migrants, members of socially oppressed ethnic and racialized populations, and

other groups facing social adversity, racism, and discrimination 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 neglect, hostility, or indifference of the majority

society (Iacovino et al. 2014; Raza et al. 2014). Some cultural groups develop low

generalized trust, especially of outgroup members, which may lead to behaviors that can be

misjudged as paranoid. These include guardedness, limited outward emotionality,

cognitive rigidity, social distance, and hostility or defensiveness in situations experienced

as unfair or discriminatory (Combs et al. 2002; Mosley et al. 2017; van der Linden 2017;

Van Hoorn 2015; Whaley 2004). These behaviors can, in turn, generate anger and

frustration in others, including clinicians, thus setting up a vicious cycle of mutual mistrust,

which should not be confused with paranoid traits or paranoid personality

disorder (Ahmed et al. 2017; Isbell et al. 2020).

Sex- and Gender-Related Diagnostic Issues

While paranoid personality disorder was found to be more common in men than in women

in a meta-analysis relying on clinical and community samples (Lynam and Widiger 2007),

the National Epidemiologic Survey on Alcohol and Related Conditions found it to be more

common in women (Grant et al. 2004).

Differential Diagnosis

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 16/98

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 a direct physiological

consequence of another medical condition.

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

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 17/98

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, and

borderline personality disorder exhibits higher levels of impulsivity and self-destructive

behavior. 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.

Comorbidity

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 co-occurring

personality disorders appear to be schizotypal, schizoid, narcissistic, avoidant, and

borderline.

References: Paranoid Personality Disorder

Ahmed S, Lee S, Shommu N, et al: Experiences of communication barriers between

physicians and immigrant patients: a systematic review and thematic synthesis. Patient

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 18/98

Experience Journal 4:122–140, 2017

Combs DR, Penn DL, Fenigstein A: Ethnic differences in subclinical paranoia: an

expansion of norms of the Paranoia Scale. Cultur Divers Ethnic Minor Psychol 8(3):248–

256, 2002

Grant BF, Hasin DS, Stinson FS, et al: Prevalence, correlates, and disability of personality

disorders in the United States: results from the National Epidemiologic Survey on Alcohol

and Related Conditions. J Clin Psychiatry 65(7):948–958, 2004

Iacovino JM, Jackson JJ, Oltmanns TF: The relative impact of socioeconomic status and

childhood trauma on black-white differences in paranoid personality disorder symptoms.

J Abnorm Psychol 123(1):225–230, 2014

Isbell LM, Tager J, Beals K, Liu G: Emotionally evocative patients in the emergency

department: a mixed methods investigation of providers’ reported emotions and

implications for patient safety. BMJ Qual Saf 29(10):1–2, 2020

Johnson JP, Cohen E, Smailes S, et al: Adolescent personality disorders associated with

violence and criminal behavior during adolescence and early adulthood. Am J Psychiatry

157(9):1406–1412, 2000

Kendler KS, Masterson CC, Davis KL: Psychiatric illness in first-degree relatives of

patients with paranoid psychosis, schizophrenia and medical illness. Br J Psychiatry

147:524–531, 1985

Lee R: Mistrustful and misunderstood: a review of paranoid personality disorder. Curr

Behav Neurosci Rep 4:151–165, 2017

Lenzenweger MF, Lane MC, Loranger AW, Kessler RC: DSM-IV personality disorders in

the National Comorbidity Survey Replication. Biol Psychiatry 62(6):553–564, 2007

Lynam DR, Widiger TA: Using a general model of personality to understand sex

differences in the personality disorders. J Pers Disord 21(6):583–602, 2007 18072861

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 19/98

(F60.1)

Morgan TA, Zimmerman M: Epidemiology of personality disorders, in Handbook of

Personality Disorders: Theory, Research, and Treatment, 2nd Edition. Edited by Livesley

WJ, Larstone R. New York, Guilford, 2018, pp 173–196

Mosley DV, Owen KH, Rostosky SS, Reese RJ: Contextualizing behaviors associated with

paranoia: perspectives of black men. Psychology of Men & Masculinity 18(2):165–175,

2017

Natsuaki MN, Cicchetti D, Rogosch FA: Examining the developmental history of child

maltreatment, peer relations, and externalizing problems among adolescents with

symptoms of paranoid personality disorder. Dev Psychopathol 21(4):1181–1193, 2009

Raza GT, DeMarce JM, Lash SJ, Parker JD: Paranoid personality disorder in the United

States: the role of race, illicit drug use, and income. J Ethn Subst Abuse 13(3):247–257,

2014

Ullrich S, Deasy D, Smith J, et al: Detecting personality disorders in the prison population

of England and Wales: comparing case identification using the SCID-II Screen and the

SCID-II Clinical Interview. Journal of Forensic Psychiatry & Psychology 19(3):301–322,

2008

van der Linden M, Hooghe M, de Vroome T, Van Laar C: Extending trust to immigrants:

generalized trust, cross-group friendship and anti-immigrant sentiments in 21 European

societies. PLoS One 12(5):e0177369, 2017

Van Hoorn A: Individualist–collectivist culture and trust radius: a multilevel approach.

Journal of Cross-Cultural Psychology 46(2):269–276, 2015

Whaley AL: Ethnicity/race, paranoia, and hospitalization for mental health problems

among men. Am J Public Health 94(1):78–81, 2004

Schizoid Personality Disorder

Diagnostic Criteria

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 20/98

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. Takes pleasure in few, if any, activities.

5. Lacks close friends or confidants other than first-degree relatives.

6. Appears indifferent to the praise or criticism of others.

7. Shows emotional coldness, detachment, or flattened affectivity.

B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder

or depressive disorder with psychotic features, another psychotic disorder, or

autism spectrum disorder and is not attributable to the physiological effects of

another medical condition.

Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,”

i.e., “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 A1). They prefer

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 21/98

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

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

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 22/98

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.

Prevalence

Schizoid personality disorder is uncommon in clinical settings. The estimated prevalence of

schizoid personality disorder based on a probability subsample from Part II of the National

Comorbidity Survey Replication was 4.9% (Lenzenweger et al. 2007). The prevalence of

schizoid personality disorder in the National Epidemiologic Survey on Alcohol and Related

Conditions was 3.1% (Grant et al. 2004). A review of six epidemiological studies (four in

the United States) found a median prevalence of 1.3% (Morgan and Zimmerman 2018).

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 interpersonal styles that may be erroneously labeled as “schizoid.” For example, those

who have moved from rural to metropolitan environments may react with “emotional

freezing” that may last for several months and manifest as solitary activities, constricted

affect, and other deficits in communication. Immigrants from other countries are

sometimes mistakenly perceived as cold, hostile, or indifferent, which may be a response to

social ostracism from the host society.

Sex- and Gender-Related Diagnostic Issues

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 23/98

While some research suggests that schizoid personality disorder may be more common in

men (Furnham and Trickey 2011), other research suggests that there is no gender

difference in prevalence (Grant et al. 2004; Lenzenweger et al. 2007).

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 individuals with autism spectrum disorder, particularly with milder forms of either

disorder, as both include a seeming indifference to companionship with others (Gadow

2013; Hopwood and Thomas 2012). However, autism spectrum disorder may be

differentiated by 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 a direct physiological

consequence of another medical condition.

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

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 24/98

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” or quite introverted may display personality traits that might

be considered schizoid, consistent with the broader conceptualization of schizoid

personality disorder as a disorder defined by pathological

introversion/detachment (Samuel and Widiger 2008). Only when these traits are inflexible

and maladaptive and cause significant functional impairment or subjective distress do they

constitute schizoid personality disorder.

Comorbidity

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.

References: Schizoid Personality Disorder

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 25/98

(F21)

Furnham A, Trickey G: Sex differences in the dark side traits. Personality and Individual

Differences 50(4):517–522, 2011

Gadow KD: Association of schizophrenia spectrum disorder and autism spectrum

disorder (ASD) symptoms in children with ASD and clinical controls. Res Dev Disabil

34(4):1289–1299, 2013

Grant BF, Hasin DS, Stinson FS, et al: Prevalence, correlates, and disability of personality

disorders in the United States: results from the National Epidemiologic Survey on Alcohol

and Related Conditions. J Clin Psychiatry 65(7):948–958, 2004

Hopwood CJ, Thomas KM: Paranoid and schizoid personality disorders, in The Oxford

Handbook of Personality Disorders. Edited by Widiger TA. New York, Oxford University

Press, 2012, pp 582–602

Lenzenweger MF, Lane MC, Loranger AW, Kessler RC: DSM-IV personality disorders in

the National Comorbidity Survey Replication. Biol Psychiatry 62(6):553–564, 2007

Morgan TA, Zimmerman M: Epidemiology of personality disorders, in Handbook of

Personality Disorders: Theory, Research, and Treatment, 2nd Edition. Edited by Livesley

WJ, Larstone R. New York, Guilford, 2018, pp 173–196

Samuel DB, Widiger TA: A meta-analytic review of the relationships between the five-

factor model and DSM-IV-TR personality disorders: a facet level analysis. Clin Psychol

Rev 28(8):1326–1342, 2008

Schizotypal Personality Disorder

Diagnostic Criteria

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:

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 26/98

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.

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 27/98

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 A1). 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 their 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,

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 28/98

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 their 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

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.

Prevalence

The estimated prevalence of schizotypal personality disorder based on a probability

subsample from Part II of the National Comorbidity Survey Replication was 3.3%

(Lenzenweger et al. 2007).The prevalence of schizotypal personality disorder in the

National Epidemiologic Survey on Alcohol and Related Conditions data was 3.9% (Pulay et

al. 2009). A review of five epidemiological studies (three in the United States) found a

median prevalence of 0.6% (Morgan and Zimmerman 2018).

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

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 29/98

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. Twin

studies indicate highly stable genetic factors and rather transient environmental factors for

an increased risk for the schizotypal syndrome (Kendler et al. 2015), and genetic risk

variants for schizophrenia may be linked to schizotypal personality disorder (e.g.,

Hodgkinson et al. 2004; Nyegaard et al. 2010). Neuroimaging studies detect group-level

differences in the size and function of specific brain regions in individuals with schizotypal

personality disorder in comparison with healthy persons, individuals with schizophrenia,

and individuals with other personality disorders (e.g., Fervaha and Remington 2013; Rosell

et al. 2014).

Culture-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 supernatural and religious beliefs and practices (life beyond death, speaking in

tongues, voodoo, shamanism, mind reading, sixth sense, evil eye, magical beliefs related to

health and illness), can appear to be schizotypal to the uninformed clinician. Thus,

observed cross-national and cross-ethnic variations in the prevalence and expression of

schizotypal traits may be a true epidemiological finding or one due to differences in the

cultural acceptance of these experiences (Fonseca-Pedrero et al. 2018; Pulay et al. 2009).

Sex- and Gender-Related Diagnostic Issues

Schizotypal personality disorder appears to be slightly more common in men than in

women (Furnham and Trickey 2011; Pulay et al. 2009).

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

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 30/98

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 a direct physiological

consequence of another medical condition.

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

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 31/98

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.

Comorbidity

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,

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 32/98

delusional disorder, or schizophrenia. There is considerable co-occurrence with schizoid,

paranoid, avoidant, and borderline personality disorders.

References: Schizotypal Personality Disorder

Fervaha G, Remington G: Neuroimaging findings in schizotypal personality disorder: a

systematic review. Prog Neuropsychopharmacol Biol Psychiatry 43:96–107, 2013

Fonseca-Pedrero E, Chan RCK, Debbané M, et al: Comparisons of schizotypal traits across

12 countries: results from the International Consortium for Schizotypy Research.

Schizophr Res 199:128–134, 2018

Furnham A, Trickey G: Sex differences in the dark side traits. Personality and Individual

Differences 50(4):517–522, 2011

Hodgkinson CA, Goldman D, Jaeger J, et al: Disrupted in schizophrenia 1 (DISC1):

association with schizophrenia, schizoaffective disorder, and bipolar disorder. Am J Hum

Genet 75(5):862–872, 2004

Kendler KS, Aggen SH, Neale MC, et al: A longitudinal twin study of cluster A personality

disorders. Psychol Med 45(7):1531–1538, 2015

Lenzenweger MF, Lane MC, Loranger AW, Kessler RC: DSM-IV personality disorders in

the National Comorbidity Survey Replication. Biol Psychiatry 62(6):553–564, 2007

Morgan TA, Zimmerman M: Epidemiology of personality disorders, in Handbook of

Personality Disorders: Theory, Research, and Treatment, 2nd Edition. Edited by Livesley

WJ, Larstone R. New York, Guilford, 2018, pp 173–196

Nyegaard M, Demontis D, Foldager L, et al: CACNA1C (rs1006737) is associated with

schizophrenia. Mol Psychiatry 15(2):119–121, 2010

Pulay AJ, Stinson FS, Dawson DA, et al: Prevalence, correlates, disability, and

comorbidity of DSM-IV schizotypal personality disorder: results from the wave 2 national

epidemiologic survey on alcohol and related conditions. Prim Care Companion J Clin

Psychiatry 11(2):53–67, 2009

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 33/98

(F60.2)

Rosell DR, Futterman SE, McMaster A, Siever LJ: Schizotypal personality disorder: a

current review. Curr Psychiatry Rep 16(7):452, 2014

Cluster B Personality Disorders

Antisocial Personality Disorder

Diagnostic Criteria

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.

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 34/98

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 evidence of conduct disorder with onset 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 A1). 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

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 35/98

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., “life’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

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. Some antisocial individuals 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 self-appraisal, and superficial charm are features that have been

commonly included in traditional conceptions of psychopathy that may be particularly

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 36/98

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 lack 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 individuals in the general

population to die prematurely from natural causes and suicide (Krasnova et al. 2019).

Prevalence

The estimated prevalence of antisocial personality disorder based on a probability

subsample from Part II of the National Comorbidity Survey Replication was 0.6%

(Lenzenweger et al. 2007).The prevalence of antisocial personality disorder in the National

Epidemiologic Survey on Alcohol and Related Conditions data was 3.6% (Grant et al.

2004). A review of seven epidemiological studies (six in the United States) found a median

prevalence of 3.6% (Morgan and Zimmerman 2018). The highest prevalence of antisocial

personality disorder (greater than 70%) is among samples of men with the most severe

alcohol use disorders (Bucholz et al. 2000) and from substance abuse clinics, prisons, or

other forensic settings (Moran et al. 1999). Lifetime prevalence appears to be similar across

non-Latinx White and Black individuals and lower in Latinx and Asian

Americans (Goldstein et al. 2017). Prevalence may be higher in sam ples 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, often by age 40 (Black 2015). Although this remission tends

to be particularly evident with respect to engaging in criminal behavior, there is likely to be

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 37/98

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

Environmental

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.

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. Biological relatives of individuals

with this disorder are also at increased risk for somatization disorder (a diagnosis that was

replaced in DSM-5 with 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 somatization disorder (Javdani et al. 2011).

Culture-Related Diagnostic Issues

Antisocial personality disorder has been associated with low socioeconomic status and

urban settings. The diagnosis may at times be misapplied to individuals in settings in which

seemingly antisocial behavior may be part of a protective survival strategy (e.g., formation

of youth gangs in urban areas with high rates of violence and discrimination). Sociocultural

contexts with high rates of child maltreatment or exposure to violence also tend to have

elevated prevalence of antisocial behaviors, suggesting either a potential risk factor for the

development of antisocial personality disorder or an adverse environment that evokes

reactive and contextual antisocial behaviors that do not represent pervasive and enduring

traits consistent with a personality disorder (Jervis et al. 2014; Kounou et al. 2015; Liu et

al. 2012). In assessing antisocial traits, it is helpful for the clinician to consider the social

and economic context in which the behaviors occur. In the National Epidemiologic Survey

on Alcohol and Related Conditions, prevalence appears to vary across U.S. ethnic and

racialized groups, possibly because of a combination of true prevalence differences,

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 38/98

measurement artifacts, and the impact of adverse environments that generate behaviors

that resemble those of antisocial personality disorder but are instead reactive and

contextual (Goldstein et al. 2017). Individuals from some socially oppressed groups may be

at higher risk for misdiagnosis or overdiagnosis of antisocial personality disorder because

they are more likely to be misdiagnosed with conduct disorder in adolescence (Baglivio et

al. 2017; Caldwell et al. 2016; Fadus et al. 2020; Mandell et al. 2007; Rousseau et al. 2008),

which is a requirement for a diagnosis of antisocial personality disorder.

Sex- and Gender-Related Diagnostic Issues

Antisocial personality disorder is three times as common in men than in women (Compton

et al. 2005). Women with antisocial personality disorder are more likely to have

experienced childhood and adult adverse experiences such as sexual abuse compared with

men (Alegria et al. 2013). Clinical presentation may vary, with men more often presenting

with irritability/aggression and reckless disregard for the safety of others compared with

women (Alegria et al. 2013). Comorbid substance use disorders are more common in men,

while comorbid mood and anxiety disorders are more common in women (Alegria et al.

2013).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 (Alegria et al. 2013; Paris et al. 2013).

Differential Diagnosis

The diagnosis of antisocial personality disorder is not given to individuals younger than 18

years and is given only if there is evidence 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

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 39/98

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 mental disorder

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 40/98

Antisocial personality disorder must be distinguished from antisocial behavior not due to a

mental disorder, for example, criminal behavior undertaken for gain that is not

accompanied by the personality features characteristic of this disorder. In these cases, the

condition adult antisocial behavior may be coded (see “Other Conditions That May Be a

Focus of Clinical Attention”).

Comorbidity

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, mood disorders, substance use disorders, somatic symptom

disorder, and gambling disorder. 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.

References: Antisocial Personality Disorder

Alegria AA, Blanco C, Petry NM, et al: Sex differences in antisocial personality disorder:

results from the National Epidemiological Survey on Alcohol and Related Conditions.

Personal Disord 4(3):214–222, 2013

Baglivio MT, Wolff KT, Piquero AR, et al: Racial/ethnic disproportionality in psychiatric

diagnoses and treatment in a sample of serious juvenile offenders. J Youth Adolesc

46(7):1424–1451, 2017

Black DW: The natural history of antisocial personality disorder. Can J Psychiatry

60(7):309–314, 2015

Bucholz KK, Hesselbrock VM, Heath AC, et al: A latent class analysis of antisocial

personality disorder symptom data from a multi-centre family study of alcoholism.

Addiction 95(4):553–567, 2000

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 41/98

Caldwell CH, Assari S, Breland-Noble AM: The epidemiology of mental disorders in

African American children and adolescents, in Handbook of Mental Health in African

American Youth. Edited by Breland-Noble AM, Al-Mateen CS, Singh NN. Cham,

Switzerland, Springer, 2016, pp 3–20

Compton WM, Conway KP, Stinson FS, et al: Prevalence, correlates, and comorbidity of

DSM-IV antisocial personality syndromes and alcohol and specific drug use disorders in

the United States: results from the National Epidemiologic Survey on Alcohol and Related

Conditions. J Clin Psychiatry 66(6):677–685, 2005

Fadus MC, Ginsburg KR, Sobowale K, et al: Unconscious bias and the diagnosis of

disruptive behavior disorders and ADHD in African American and Hispanic youth. Acad

Psychiatry 44(1):95–102, 2020

Goldstein RB, Chou SP, Saha TD, et al: The epidemiology of antisocial behavioral

syndromes in adulthood: results from the National Epidemiologic Survey on Alcohol and

Related Conditions–III. J Clin Psychiatry 78(1):90–98, 2017

Grant BF, Stinson FS, Dawson DA, et al: Co-occurrence of 12-month alcohol and drug use

disorders and personality disorders in the United States: results from the National

Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry

61(4):361–368, 2004

Javdani S, Sadeh N, Verona E: Expanding our lens: female pathways to antisocial

behavior in adolescence and adulthood. Clin Psychol Rev 31(8):1324–1348, 2011

Jervis LL, Spicer P, Belcourt A, et al: The social construction of violence among Northern

Plains tribal members with antisocial personality disorder and alcohol use disorder.

Transcult Psychiatry 51(1):23–46, 2014

Kounou KB, Dogbe Foli AA, Djassoa G, et al: Childhood maltreatment and personality

disorders in patients with a major depressive disorder: a comparative study between

France and Togo. Transcult Psychiatry 52(5):681–699, 2015

Krasnova A, Eaton WW, Samuels JF: Antisocial personality and risks of cause-specific

mortality: results from the Epidemiologic Catchment Area study with 27 years of follow-

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 42/98

(F60.3)

up. Soc Psychiatry Psychiatr Epidemiol 54(5):617–625, 2019

Lenzenweger MF, Lane MC, Loranger AW, Kessler RC: DSM-IV personality disorders in

the National Comorbidity Survey Replication. Biol Psychiatry 62(6):553–564, 2007

Liu N, Zhang Y, Brady HJ, et al: Relation between childhood maltreatment and severe

intrafamilial male-perpetrated physical violence in Chinese community: the mediating

role of borderline and antisocial personality disorder features. Aggress Behav 38(1):64–

76, 2012

Mandell DS, Ittenbach RF, Levy SE, Pinto-Martin JA: Disparities in diagnoses received

prior to a diagnosis of autism spectrum disorder. J Autism Dev Disord 37(9):1795–1802,

2007 17160456

Moran P: The epidemiology of antisocial personality disorder. Soc Psychiatry Psychiatr

Epidemiol 34(5):231–242, 1999

Morgan TA, Zimmerman M: Epidemiology of personality disorders, in Handbook of

Personality Disorders: Theory, Research, and Treatment, 2nd Edition. Edited by Livesley

WJ, Larstone R. New York, Guilford, 2018, pp 173–196

Paris J, Chenard-Poirier M-P, Biskin R: Antisocial and borderline personality disorders

revisited. Compr Psychiatry 54(4):321–325, 2013

Rousseau C, Hassan G, Measham T, Lashley M: Prevalence and correlates of conduct

disorder and problem behavior in Caribbean and Filipino immigrant adolescents. Eur

Child Adolesc Psychiatry 17(5):264–273, 2008

Borderline Personality Disorder

Diagnostic Criteria

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:

8/3/22, 9:36 AM Psychiatry Online | DSM Library

https://dsm.psychiatryonline.org/doi/10.1176/appi.books.9780890425787.x18_Personality_Disorders 43/98

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 self-mutilating behavior covered in Criterion 5.)

5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.

6. Affective instability due to a marked reactivity of mood (e.g., intense episodic

dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more

than a few days).

7. Chronic feelings of emptiness.

8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays

of temper, constant anger, recurrent physical fights).

9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

bottom of post
Scroll to Top