Lecture 1: PD Diagnoses and Assessment
40-60% of clinical patients, 10.5-12% of general population
Personality: the enduring characteristics and behavior that comprise a person's unique
adjustments to life, including major traits, interests, drives, values, self-concept, abilities and
emotional patterns
PDs are egosyntonic (belonging to them, unlike egodystonic such as anxiety) and interfere
with adaptive interpersonal functioning
General criteria of PD:
- Pervasive: in several domains of life
- Persistent: from early adulthood
- Pathological: divergent from the norm
Inflexible and stable patterns of self and interpersonal functioning that we label as PDs:
- Behavioral functioning: e.g. recurrent devaluation / idealization, difficulties maintaining
healthy friendships, risk taking behavior, avoiding activities due to anxiety to be rejected
- Affective functioning: e.g. emotional instability, feeling isolated, levels of positive and
negative affect
- Cognitive functioning: e.g. development of maladaptive schemas (I need others to
survive and be happy), problems with theory of mind, levels of self-esteem
- Neurocognitive functioning: e.g. impulsivity, problems with behavioral inhibitions,
difficulty recognizing or regulating emotions
PD criteria DSM-5
A. An enduring pattern of inner experience and behavior that deviates markedly from the
expectations of the individual’s culture, manifested in 2 or more
1. Cognition
2. Affectivity
3. Interpersonal functioning
4. Impulse control
B. An 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 (functional impairment and distress)
D. The pattern is stable and of long duration, and its onset can be tracked to adolescence
or early adulthood
E. The enduring pattern is not better accounted for as a manifestation or consequence of
another mental disorder
F. Not due to the direct physiological effects of a substance (drugs), or a general medical
condition (head trauma)
Cluster A - Odd (4%)
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,Paranoid PD: pervasive distrust and suspiciousness of others such as that their motives are
malevolent, begins in early adulthood, 4 or more
- Suspects that others are exploiting, harming or deceiving
- Preoccupied with unjustified doubts about the loyalty or trustworthiness of friends and
associates
- Reluctant to confide in others because of unwarranted fear that the information will be
used maliciously against them
- Reads hidden meaning or threatening meaning into benign remarks or events
- Persistently bears grudges
- Perceives attacks on their character or reputation that are not apparent to others and is
quick to react angrily or to counterattack
- Has recurrent suspicions regarding fidelity of spouse or sexual partner
Does not occur exclusively during the course of schizophrenia, bipolar disorder, depressive
disorder with psychotic features, psychotic disorder, not attributable to the direct effect of
another medical condition
Schizoid PD: detachment from social relationships and restricted range of expression of
emotions in interpersonal setting, begins in early adulthood, 4 or more
- Neither desire nor enjoy close relationships, including family
- Almost always chooses solitary activities
- Has little interest in having sexual experiences
- Takes pleasure in few, if any, activities
- Lacks close friends or confidants, other than first degree relatives
- Appears indifferent to the praise or criticism of others
- Shows emotional coldness, detachment or flattened affectivity
** or autism spectrum disorder
Schizotypal PD: social and interpersonal deficits, acute discomfort with close relationships,
cognitive and perceptual distortions and eccentricities of behavior, begins in early adulthood, 5
or more
- Ideas of reference (excluding delusions of reference)
- Odd beliefs or magical thinking that influence behavior and is inconsistent with
subcultural norms (superstitiousness, telepathy, 6th sense)
- Unusual perceptual experiences, including bodily illusions
- Odd thinking and speech (vague, circumstantial, metaphoric, over elaborate or
stereotyped)
- Suspiciousness or paranoid ideation
- Inappropriate or constricted affect
- Behavior or appearance that is odd, eccentric or peculiar
- Lack of close friends or confidants other than first-degree relatives
- Excessive social anxiety that does not diminish with familiarity and tends to be
associated with paranoid fears rather than negative judgements about self
Does not occur exclusively during the course of schizophrenia, bipolar disorder, depressive
disorder with psychotic features, another psychotic disorder, or autism spectrum disorder
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,Cluster B - Dramatic (3.5-4%)
Antisocial PD: disregard for and violation of the rights of others, since age 15, 3 or more
- Failure to conform to social norms
- Deceitfulness for pleasure
- Impulsivity or failure to plan ahead
- Irritability and aggressiveness, indicated by physical fights or assaults
- Reckless disregard for safety of self and others
- Consistent irresponsibility, indicated by repeated failure to sustain consistent work
behavior or honor financial obligation
- Lack of remorse, indifferent to hurting, mistreating or stealing from another
The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or
bipolar disorder
At least 18 years old to diagnose
There is evidence of conduct disorder with onset before age 15
Borderline PD: instability of interpersonal relationships, self-image and affects, impulsivity,
begins in early adulthood, 5 or more
- Frantic efforts to avoid real or imagined abandonment
- Pattern of unstable and intense interpersonal relationships, altering between extremes of
idealization and devaluation
- Identity disturbance: unstable self-image or sense of self
- Impulsivity in at least two areas that are potentially self-damaging (spending, sex,
substance abuse, reckless driving, binge eating)
- Recurrent suicidal behavior, gestures or threats, self-mutilating behavior
- Instability due to reactivity of mood (intense episodic dysphoria, irritability, anxiety for a
few hours)
- Chronic feeling of emptiness
- Inappropriate, intense anger or difficulty controlling anger
- Transient, stress-related paranoid ideation or severe dissociative symptoms
Histrionic PD: excessive emotionality and attention seeking, begins in early adulthood, 5 or
more
- Uncomfortable in situations in which they’re not the center of attention
- Interaction with others often involving inappropriate sexually seductive or provocative
behavior
- Displays rapidly shifting and shallow expression of emotions
- Consistently uses physical appearance to draw attention to self
- Style of speech that is excessively impressionistic and lacking in detail
- Shows self-dramatization, theatricality and exaggerated emotion
- Is suggestible
- Considers relationships to be more intimate than they actually are
Narcissistic PD: grandiosity, need for admiration, lack of empathy, begins in early adulthood,
5 or more
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, - Grandiose sense of self-importance
- Preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love
- Believes they’re special and unique and should only associate with high status people
- Requires excessive admiration
- Sense of entitlement
- Inappropriately exploitative
- Lacks empathy
- Often envious of others or believes others are envious of them
- Arrogant, haughty behavior or attitudes
Cluster C - Anxious (3-9%)
Avoidant PD: pattern of social inhibitions, feelings of inadequacy and hypersensitivity to
negative evaluations, emotional, begins in early adulthood, 4 or more
- Avoids occupational activities that involve significant interpersonal contact, because of
fears of criticism, disapproval or rejection
- Unwilling to get involved with people unless certain of being liked
- Shows restraint with intimate relationships because of the fear of being ashamed or
ridiculed
- Preoccupied with being criticized or rejected in social situations
- Inhibited in new interpersonal situations because of feelings of inadequacy
- View of self as socially inept, personally unappealing or inferior to others
- Unusually reluctant to take personal risks or to engage in any new activities because
they may prove embarrassing
Dependent PD: excessive need to be taken care of that leads to submissive and clinging
behavior and fears of separation, begins in early adulthood, 5 or more
- Difficulty making everyday decisions without an excessive amount of advice and
reassurance from others
- Needs others to assume responsibility for most major areas of their life
- Difficulty expressing disagreement because of fear of loss of support or approval
- Difficulty initiating projects or doing things on their own (lack of confidence)
- Goes to excessive lengths to obtain nurturance and support from others, volunteering to
do unpleasant things
- Feels uncomfortable or helpless when alone because of exaggerated fears of being
unable to care for themself
- Urgently seeks another relationship as a source of care and support when a close
relationship ends
- Unrealistically preoccupied with fears of being left to take care of themself
Obsessive-compulsive PD: preoccupation of orderliness, perfectionism and mental and
interpersonal control, at the expense of flexibility, openness and efficiency, begins in early
adulthood, 4 or more
- Preoccupied with details, rules, lists, order, organization or schedule to the point where
the major point to the activity is lost
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