Week 1 – Part 1: Personality disorders:
Reading 1: APA – DSM-5 criteria:
PERSONALITY DISORDERS (DSM-5 criteria)
(p. 677)
• INTRO:
o Clusters help in diagnosis & education but are not fully valid
o Prevalence = 5.7% in cluster A – 1.5% in B – 6% in C – 9.1% for any PD (i.e., at
least one PD; doesn’t count comorbidity)
§ At least 15% of US adults have at least 1 PD
• Development & course:
o Often recognizable during adolescence or early adult life
o Enduring pattern of thinking, feeling, behaving stable over time
o Not caused by another disorder
o Need to have been present for at least 1 year in > 18-year-old
§ Except Antisocial PD (need to be 18+ for diagnosis)
• Culture = can’t be explained by acculturation problems
• Gender = depends (antisocial more in M – borderline, histrionic, dependent more in F)
• Differential diagnosis:
o PD = inflexible, maladaptive, persisting, cause sig impairment
o Must not have occurred only during psychotic disorder episode (schizophrenia)
o Look out for possible mood disorder, PTSD, SUD, medication used
• Traits must be inflexible; maladaptive; persisting (persistent, pervasive, pathological) +
cause significant impairment & distress
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,• Associated features:
o Difficult to get along with – problems in close relationships
o Hypervigilant for potential threats = hostile, sarcastic, stubborn to you
§ May blame others – want to confirm their beliefs of people being bad
o Can experience brief psychotic episodes
§ Higher risk of depression, agoraphobia, OCD, SUD
o Common comorbidity = schizotypal; schizoid; narcissistic; avoidant; borderline PDs
• Prevalence = 2.3-4.4% | More common in M
• Course = start in childhood (few peer relations, social anxiety, teased, poor school)
• Risk = schizophrenia, delusional disorder in family
• Culture = can’t be caused by acculturation/unfamiliarity (can cause anger)
• Differential diagnosis:
o Must be present prior & post onset of psychotic symptoms of other disorder
o Personality changes not caused by another medical condition
o ≠ SUD or development of handicap (e.g., hearing impairment)
o Can be diagnosed with other PDs
§ Schizoid is different cause of magic thinking, odd thinking/speech/visual
§ ≠ Borderline or histrionic cause no pervasive suspiciousness
§ ≠ Narcissistic might alienate themselves but only to hide flaws
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,• Associated features:
o Difficulty expressing anger (even with direct provocation) – lack emotions?
o Difficulty responding appropriately to big life events
§ Poor social skills -> few friends + often unmarried
o Often premorbid to schizophrenia or depression
o Common comorbidity = schizotypal; paranoid; avoidant PDs
• Prevalence = 3.2-4.9% | Slightly more common in M + causes more impairment in them
• Course = few friends in childhood – underachievement in school – teased
• Risk = higher if family with schizophrenia or schizotypal PD
• Culture = not defense behavior – cultural differences in what is “hostile/cold”
• Differential diagnosis:
o Most be present prior/post onset of psychotic symptoms from another disorder
o ≠ Autism (ASD) – more severely impaired interaction & stereotyped behaviors
o Personality changes not caused by another medical condition
o ≠ SUD
o Other PDs (can diagnose multiple PDs)
§ ≠ Schizotypal – cognitive & perceptual distortions (not in schizoid)
§ ≠ Paranoid – suspiciousness & paranoid ideation
§ ≠ OCPD – social detachment but still have underlying capacity for intimacy
o à Traits must be dysfunctional & maladaptive + cause sig impairment
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,(Magical thinking = thought that you can influence the outcome of specific events by doing something that has
no bearing on the circumstances)
• Associated features:
o They often seek treatment for linked anxiety or depression
o Common to also have major depressive disorder
o Common comorbidities = schizoid; paranoid; avoidant; borderline PDs
• Prevalence = 0.6-4.6% (˜3.9%) | Slightly more common in M
• Course = stable (only small proportion develop a psychotic disorder) – few friends –
hypersensitivity – poor school – social anxiety – bizarre fantasies/thoughts/language
• Risk = higher in 1st degree relatives of people with schizophrenia
• Culture = can’t link to religious beliefs & rituals
• Differential diagnosis:
o Most be present prior/post onset of psychotic symptoms from another disorder
o ≠ Autism/communication disorders – greater lack of social awareness &
emotional reciprocity
o Personality changes not caused by another medical condition
o ≠ SUD
o Other PDs (can diagnose multiple PDs)
§ ≠ Paranoid or schizoid – presence of perceptual distortions + eccentricity in
schizotypal
§ ≠ Avoidant – lack of desire of social relations in schizotypal
§ ≠ Narcissistic – might alienate themselves but only to hide flaws
§ ≠ BPD – also psychotic symptoms but more in response to stress & severe +
social isolation due to angry outburst (> not wanting it) + impulsive &
manipulative
• High comorbidity between the two
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,• Associated features:
o Cynical of others – little care for their feelings & rights – low empathy
o V self-opinionated; self-assured; cocky – superficial charm – don’t care for rules
o Common to have many partners + irresponsible parents
§ More likely to dies early by violent means (e.g., suicide, accident)
o Linked to other impulse control disorders (SUD, gambling, anxiety, depression)
o Common comorbidity = borderline; histrionic; narcissistic PDs
§ Increased risk if conduct disorder in childhood + ADHD – trauma
• Prevalence = 0.2-3.3% (higher in low SES) | Way more common in M (cause of aggression?)
• Course = chronic but less evident later in life – need to be 18 for diagnosis
• Risk = 1st degree relatives lead to higher risks (especially with F relative with ASPD) –
biological & environmental risk
• Culture = linked to low SES & urban setting – can be used as protective strategy by some
• Differential diagnosis:
o Need to be 18 + have a history of conduct disorder prior 15 years
o SUD – only diagnose both if both started in childhood & continued after
o No diagnosis if only happens during schizophrenia or bipolar
o Other PDs (can diagnose multiple PDs)
§ ≠ Narcissistic – doesn’t include impulsivity; aggression; deceit + no need for
childhood conduct disorder (seen in ASPD)
§ ≠ Histrionic – more exaggerated in emotions + no antisocial behavior (≠
ASPD) – ASPD = manipulate to gain profit/power
§ ≠ Borderline – less emotionally unstable + more aggressive in ASPD
§ ≠ Paranoid don’t avoid people for personal gain (≠ ASPD)
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,• Associated features:
o Undermine self right before goal is reached (e.g., drop out before graduating)
o Possible psychotic-like symptoms during times of stress
§ Can feel more secure with inanimate object > real person
§ Premature death from suicide is common (with depression or SUD)
o Common past physical/sexual abuse, loss of a parent
o Common with depression; bipolar; SUD; ADHD; PTSD; eating disorder
• Prevalence = 1.6-5.9% (lower in older ages) | More common in F (75%)
• Course = higher suicide risk in young adults – chronic instability – improvement in 1st
year of treatment – stability in 30-40s – 50% recover after 10 years of treatment
• Risk = 5x more common in 1st degree relatives – also higher risk for ASPD, depression, bipolar
• Culture = not just emotional instability (e.g., existential crisis, gender identity…)
• Differential diagnosis:
o Can be comorbid with depression or bipolar (check it exists pre or post it)
o Personality changes not caused by another medical condition
o ≠ SUD
o Not linked to an identity problem in developmental phase
o Other PDs (can diagnose multiple PDs)
§ ≠ Histrionic – BPD has self-destruction, anger, loneliness, empty, poor relations
§ ≠ Schizotypal – illusions in response to external structuring in BPD
§ ≠ Paranoid & narcissistic – impulsivity, self-destructiveness only in BPD
§ ≠ ASPD – manipulative to gain profit/power ≠ BPD for concern of others
§ ≠ Dependent – fear of abandonment leads to anger > submissive in BPD
o à Common unstable & intense relationships
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,• Associated features:
o Difficulties with emotional intimacy & sexual relationships
§ Can be emotionally manipulative & dependent at same time
o Act as the “princess” or “victim” in relationships – push away other eccentrics
o Few relations with same-sex people (seen as threat)
o Look for short-term/immediate rewards
o Higher risk of suicide + threat for attention
o Risk of somatic symptoms; conversion disorder, depression
o Common comorbidity = BPD; narcissistic; ASPD; dependent
• Prevalence = 1.84% | Similar M:F rates (more F in clinical setting in general)
• Culture = symptoms must cause sig impairment – some can be linked to culture, age…
• Differential diagnosis:
o Personality changes not caused by another medical condition
o ≠ SUD
o Other PDs (can diagnose multiple PDs)
§ ≠ BPD – attention & manipulation here is for anger, self-destruction, emptiness
§ ≠ ASPD – no antisocial behavior + more exaggerated impulsive, seductive…
§ Manipulation to gain nurturance here (> profit in ASPD)
§ ≠ Narcissistic – attention for superiority (can be fragile in histrionic)
§ ≠ Dependent – need others for praise & guidance (> emotional features)
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,• Associated features:
o Vulnerable self-esteem -> sensitive to criticism (humiliated, degraded, empty)
§ May not react or show anger – want to protect their ego
o Entitlement – need for admiration -> difficulties in relationships
o Can show unwillingness to compete
o Shame can lead to social withdrawal, depressed mood…
§ Grandiosity can lead to hypomanic mood
o Risk of anorexia, SUD (cocaine)
o Common comorbidity = histrionic; BPD; ASPD; paranoid
• Prevalence = 0-6.2% | More common in M (50-75%)
• Course = can show narcissistic traits in ado without developing the disorder – they are
often v affected by limitations that come with aging
• Differential diagnosis:
o Grandiosity should not come from manic/hypomanic episode
o ≠ SUD
o Other PDs (can diagnose multiple PDs)
§ ≠ Histrionic, antisocial, borderline – grandiosity is big in narcissistic
• ≠ BPD – stable self-image, no self-destruction, impulsivity in N
• ≠ Histrionic – pride in achievement, low emotions, low empathy
• ≠ ASPD – no aggression, impulsivity, deceit in N
§ Lack of history of conduct disorder
§ ≠ OCPD – no self-criticism
§ ≠ Schizotypal, paranoid – suspiciousness & social withdrawal
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,• Associated features:
o Very anxious about possible criticism – described as “shy”, “lonely”, “isolated”
o Difficulties in social life & work in fear of rejection
§ Small social network though they want relationships with others
o Risk for depression, bipolar, anxiety (social)
o Common comorbidity = dependent (v attached to the few friends they have),
BPD, and cluster A PDs
• Prevalence = 2.4% | Equally frequent in M & F
• Course = shyness, isolation, fear of strangers… in childhood – become increasingly shy in
ado & adulthood (when new relations are important) – disorder severity lowers with age
• Culture = cultural differences in what level of avoidance is appropriate
• Differential diagnosis:
o Big overlap with social phobia – different forms of same condition
o Personality changes not caused by another medical condition
o ≠ SUD
o Other PDs (can diagnose multiple PDs)
§ ≠ Dependent – humiliation & rejection are key to criticism fear in A
• V likely to co-occur
§ ≠ Schizoid, schizotypal – would actually like social relations in A
§ ≠ Paranoid – low socialization for fear of embarrassment in Avoidant
o à Traits must be inflexible, maladaptive, persisting!!
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, • Associated features:
o Self-doubt – belittle their abilities & assets (label self as “stupid”)
o Take disapproval/criticism as proof of their worthlessness
o Seek overprotection & dominance from others – few v close relationships
§ Anxious when facing a decision – avoid responsibility
o Risk of depression, anxiety, adjustment disorders
o Common comorbidity = BPD, avoidant, histrionic
o Chronic physical illness, separation anxiety in childhood is good predictor
• Prevalence = 0.49-0.6% | Mixed (some say equal; others say more in F in clinical setting)
• Course = be cautious with diagnosis – check for appropriate developmental stages
• Culture = appropriate dependence varies across age & SES – need unrealistic concerns +
excessive dependence – also gender difference on how society treats our independence
• Differential diagnosis:
o Cannot be cause by consequence of other mental/medical disorder
o Personality changes not caused by another medical condition
o ≠ SUD
o Other PDs (can diagnose multiple PDs)
§ Predominant submissive, reactive, clinging in DPD
§ ≠ BPD – fear of abandonment leads to submissiveness here
§ ≠ Histrionic – also want reassurance & approval but less for attention in DPD
§ ≠ Avoidance – seek & maintain important connections > acceptance PDP
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