This section begins with a general definition of Personality Disorder that applies to each of the 10 specific Personality Disorders.  A personality Disorder is an enduring of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early a adulthood, is stable over time, and leads to distress or impairment.  The Personality Disorders included in this section are listed below.
 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 relationship, cognitive or perceptual distortions. and eccentricities of behavior.
 Antisocial Personality Disorder is a pattern of disregard for, and violation of, the rights of others.
 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 Disorder Not Otherwise Specified  is a category provided for two situations: 1) the individual’s personality pattern meets the general criteria for a Personality Disorder and traits of several different Personality Disorders are present, but the criteria for any specific Personality Disorder are not met; or 2) the individual’s personality pattern meets the general criteria for a Personality Disorder, but the individual is considered to have a Personality Disorder that is not included in the Classification (e.g., passive-aggressive personality disorder).
 The Personality Disorders are grouped into three clusters based on descriptive similarities.  Cluster A includes the Paranoid, Schizoid, and Schizotypal Personality Disorders.  Individuals with these disorders often appear odd or eccentric.  Cluster B includes the Antisocial, Borderline, Histrionic, and Narcissistic Personality Disorders Individuals with these disorders often appear dramatic, emotional or erratic.  Cluster C includes the Avoidant, Dependent, and Obsessive-Compulsive Personality Disorders.  Individuals with these disorders often appear anxious or fearful.  It should be noted that this clustering system, although useful in some research and educational situations, has serious limitations and has not been consistently validated.  Moreover, individuals frequently present with co-occurring Personality Disorders from different cluster.

Disgnostic Features
Personality traits are enduring patterns of perceiving, relating to, and thinking about the enviroment 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 of subjective distress do they constiture Personality Disorders.  The essential feature of a Personality Disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture and is manifested in at least two of the following areas: cognition, affectivity, interpersonal functioning, or impulse control (Criterion A).  This enduring patterm is inflexible and pervasive across a broad range of personal and social situations (Criterion B) and leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion C).  The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood (Criterion D).  The pattern is not better accounted for as a manifestation or consequence of another mental disorder (Criterion E) and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, exposure to a toxin) or a general medical condition (e.g., head trauma) (Criterion F).  Specific diagnostic criteria are also provided for each of the Personality Disorders included in this section.  The items in the criteria sets for each of the specific Personality Disorders are listed in order of decreasing diagnostic importance as measured by relevant data on diagnostic efficiency (when available).
 The diagnosis of Personality Disorders requires an evaluation of the individual’s long-term patterns of functioning, and the particular personality features must be evident by early adulthood.  The personality traits that define these disorders must also be distinguished from characteristics that emerge in response to specific situational stressors or more transient mental states (e.g., Mood or Anxiety Disorders, Substance Intoxication). The clinician should assess the stability of personality traits over time and across different situations.  Although a single interview with the person is sometimes sufficient for making the diagnosis, it is often necessary to conduct more than one interview and to space these over time.  Assessment can also be complicated by the fact that the characteristics that define a Personality Disorder may not be considered problematic by the individual (i.e., the traits are often ego-syntonic).  To help overcome this difficulty, supplementary information from other informants may be helpful.

Recording Procedures
Personality Disorders are coded on Axis II.  When (as is often the case) an individual’s pattern of behavior meets criteria for more than one Personality Disorder, the clinician should list all relevant Personality Disorder diagnoses in order of importance.  When an Axis I disorder is not the principal diagnosis or the reason for visit, the clinician is encouraged to indicate which Personality Disorder is the principal diagnosis or the reason for visit by noting "Principal Diagnosis" or "Reason for Visit" in parentheses.  In most cases, the principal diagnosis or the reason for visit is also the main focus of attention or treatment.  Personality Disorer Not Otherwise Specified is the appropriate diagnosis for a "mixed" presentation in which criteria are not met for any single Personality Disorder but features of several Personality Disorders are present and involve dinically significant impairment.
 Specific maladaptive personality traits that do not meet the threshold for a Personality Disorder may also be listed on Axis II.  In such instances, no specific code should be used; for example, the clinician might record "Axis II: V71.09 No diagnosis on Axis II, histrionic personality traits."  The use of particular defense mechanisms may also be indicated on Axis II.  For example, a clinician might record "Axis II: 301.6 Dependent Personality Disorder; Frequent use of denial." Glossary definition for specific defense mechanisms and the Defensive Functioning Scale appear in Appendix B (p.751).
 When an individual has a chronic Axis I Psychotic Disorder (e.g., Schizophrenia) that was preceded by a preexisting Personality Disorder (e.g., Schizotypal, Schizoid, Paranoid), the Personality Disorder should be recorded on Axis II, followed by "Premorbid" in parentheses.  For example: Axis I: 295.30 Schizophrenia, Paranoid Type; Axis II: 301.20 Schizoid Personality Disorder (Premorbid).

Specific Culture, Age, and Gender Features
Judgments about personality functioning must take into account the individual’s ethnic, cultural, and social background.  Personality Disorders should not be confused with problems associated with acculturation following immigration or with the expression of habits, customs, or religious and political values professed by the individual’s culture of origin.  Especially when evaluating someone from a different background, it is useful for the clinician to obtain additional information from informants who are familiar with the person’s cultural background.
 Personality Disorder categories may be applied to children or adolescents in those relatively unusual instances in which the individual’s particular maladaptive personality traits appear to be pervasive, persistent, and unlikely to be limited to a particular developmental stage or an episode of an Axis I disorder.  It should be recognized that the traits of a personality Disorder that appear in childhood will often not persist unchanged into adult life.  To diagnose a Personality Disorder in an individual under age 18 years, the features must have been present for at least 1 year.  The one exception to this is Antisocial Personality Disorder, which cannot be diagnosed in individuals under age 18 years (see p. 645).  Although, by definition, a Personality Disorder requires an onset not later than early adulthood, individuals may not come to clinical attention until relatively late in life.  A Personality Disorder may be exacerbated following the loss of significant supporting persons (e.g., a spouse) or previously stabilizing social situations (e.g., a job).  However, the development of a change in personality in middle adulthood or later life warrants a thorough evaluation to determine the possible presence of a Personality Change Due to a General Medical Condition or an unrecognized Substance Related Disorder.
 Certain Personality Disorders (e.g., Antisocial Personality Disorder) are diagnosed more frequently in men.  Others (e.g., Borderline, Histrionic, and Dependent Personality Disorders) are diagnosed more frequently in women.  Although these differences in prevalence probably reflect real gender differences in the presence of such pattems, clinicians must be cautious not to overdiagnose or underdiagnose certain Personality Disorders in females or in males because of social stereotypes about typical gender roles and behaviors.

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

Differential Diagnosis
Many of the specific criteria for the Personality Disorders describe features (e.g., suspiciousness, dependency, or insensitivity) that are also characteristic of episodes of Axis mental disorders.  A Personality Disorder should be diagnosed only when the defining characteristics appeared before early adulthood, are typical of the individual’s long-term functioning, and do not occur exclusively during an episode of an Axis I disorder.  If may be particularly difficult (and not particularly useful) to distinguish Personality Disorders from those Axis I disorders (e.g., Dysthymic Disorder) that have an early onset and a chronic, relatively stable course.  Some Personality Disorders may have a "spectrum" relationship to particular Axis I conditions (e.g., Schizotypal Personality Disorder with Schizophrenia: Avoidant Personality Disorder with Social Phobia) based on phenomenological or biological similarities or familial aggregation.
 For the three Personality Disorders that may be related to the Psychotic Disorders (i.e., Paranoid, Schizoid, and Schizotypal), there is an exclusion criterion stating that thepattern of behavior must not have occurred exclusively during the course of Schizophrenia, a Mood Disorder With Psychotic Features, or another Psychotic Disorder.  When an individual has a chronic Axis I Psychotic Disorder (e.g., Schizophrenia) that was preceded by a preexisting Personality Disorder, the Personality Disorder should also be recorded, on Axis II. followed by "Premorbid" in parentheses.
 The clinician must be cautious in diagnosing Personality Disorders during an episode of a Mood Disorder or an Anxiety Disorder because these conditions may have cross-sectional symptom features that mimic personality traits and may make it more difficult to evaluate retrospectively the individual’s long-term patterns of functioning.  When personality changes emerge and persist after an individual has been exposed to extreme stress, a diagnosis of Posttraumatic Stress Disorder should be considered (see p. 424).  When a person has a Substance-Related Disorder, it is important not to make a Personality Disorder diagnosis based solely on behaviors that are consequences of Substance Intoxication or Withdrawal or that are associated with activities in the service of sustaining a dependency (e.g., antisocial behavior).  When enduring changes in personality arise as a result of thedirect physiological effects of a general medical condition (e.g., brain tumor), a diagnosis of Personality Change Due to a General Medical Condition (p. 171) should be considered. Personality Disorders must be distinguished from personality traits that do not reach the threshold for a Personality Disorder.   Personality traits are diagnosed as a Personality Disorder only when they are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Dimensional Models for Personality Disorders
The diagnostic approach used in this manual represents the categorical perspective that Personality Disorders represent qualitatively distinct clinical syndromes.  An alternative to the categorical approach is the dimensional perspective that Personality Disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another.  There have been many different attempts to identify the most fundamental dimensions that underlie the entire domain of normal and pathological personality functioning.  One model consists of the following five dimensions: neuroticism, introversion versus extroversion, closedness versus openness to experience, antagonism versus a greeableness, and conscientiousness.  Another approach is to describe more specific areas of personality dysfunction, including as many as 15-40 dimensions (e.g., affective reactivity, reactivity, social apprehensiveness, cognitive distortion, impulsivity, insincerity, self-centeredness).   Other dimensions that have been studied include novelty seeking, reward dependence, harm avoidance, dominance, affiliation, constraint, persistence, positive emotionality versus negative emotionality, pleasure seeking versus pain avoidance, passive accommodation versus active modification, and self-propagation versus other nurturance.  The DSM-IV Personality Disorder clusters (i.e., odd-eccentric, dramatic-emotional, and anxious-fearful) may also be viewed as dimensions representing spectra of personality dysfunction on a continuum with Axis I mental disorders.   The relationship of the various dimensional models to the Personality Disorder diagnostic categories and to various’ aspects of personality dysfunction remains under active investigation.

Cluster A Personality Disorders
301.0  Paranoid Personality Disorder

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 whows loyalty that they cannot trust or believe it.  It they get into trouble, they expect that friends and associates will either attack or ignore them.
 Individuals with this 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 question, saving 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 may view a casual humorous remark by a co-worker as a serious character attack.  Compliments are often misinterpreted (e.g., a compliment on a new acquisition is misinterpreted as a criticism for selfishness; a compliment on an accomplishment is misinterpreted as an attempt to coerce more and better performance).  They may view an offer of help as a criticism that they are not doing well enough on their own.
 Individuals with this disorder persistently bear grudges and are unwilling to forgive the insults, injuries, or slights that they think they have received (Criterion A5).  Minor slights arouse major hostility, and the hostile feelings persist for a long time.  Because they are constantly vigilant to the harmful intentions of others, they very often feel that their character or reputation has been attacked or that they have been slighted in some other way.  They are quick to counterattack and react with anger to perceived insults (Criterion A6).  Individuals with this disorder may be pathologically jealous, often suspecting that their spouse or sexual partner is unfaithful without any adequate justification (Criterion A7).  They may gather trivial and circumstantial "evidence" to support their jealous beliefs.  They want to maintain complete control of intimate relationships to avoid being betrayed and may constantly question and challenge the whereabouts, actions, intentions, and fidelity of their spouse or partner.
 Paranoid Personality Disorder should not be diagnosed if the pattern of behavior occurs exclusively during the course of Schizophrenia, a Mood Disorder With Psychotic Features, or another Psychotic Disorder or if it is due to the direct physiological effects of a neurological (e.g., temporal lobe epilepsy) or other general medical condition (Criterion B).

Associated Features and Disorders
Individuals with Paranoid Personality Disorder are generally difficult to get along with and often have problems with close relationships.  Their excessive suspiciousness and hostility may be expressed in overt argumentativeness, in recurrent complaining, or by quiet, apparently hostile aloofness.  Because they are hypervigilant for potential threats, they may act in a guarded, secretive, or devious manner and appear to be "cold" and lacking in tender feelings.  Although they may appear to be objective, rational, and unemotional, they more often display a labile range of affect, with hostile, stubborn, and sarcastic expressions predominating.  Their combative and suspicious nature may elicit a hostile response in others, which then serves to confirm their original expectations.
 Because individuals with Paranoid Personality Disorder lack trust in others, they have an excessive need to be self-sufficient and a strong sense of autonomy.  They also need to have a high degree of control over those around them.  They are often rigid, critical of others, and unable to collaborate, although they have great difficulty accepting criticism themselves.  They may blame others for their own shortcomings.  Because of their quickness to counterattack in response to the threats they perceive around them, they may be litigious and frequently become involved in legal disputes.  Individuals with this disorder seek to confirm their preconceived negative notions regarding people or situations they encounter, attributing malevolent motivations to others that are projection 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 adbiguous situations.  They may be perceived as "fanatics" and form tightly knit "cults" or groups with others who share their paraoid belief systems.
 Particularly in response to stress, individuals with this disorder may experience very brief psychotic episodes (lasting minutes to hours).  In some instances, Paranoid Personality Disorder may appear as the premorbid antecedent of Delusional Disorder or Schizophrenia.  Individuals with this disorder may develop Major Depressive Disorder and may be at increased risk for Agoraphobia and Obsessive-Compulsive Disorder.  Alcohol and other Substance Abuse or Dependence frequently occur.  The most common co-occurring Personality Disorders appear to be Schizotypal, Schizoid, Narcissistic, Avoidant, and Borderline.

Specific Culture, Age, and Gender Features
Some behaviors that are influenced by sociocultural contexts or specific life circumstances may be erroneously labeled paranoid and may even be reinforced by the process of clinical evaluation.  Members of minority groups, immigrants, political and economic refugees, or individuals of different ethnic backgrounds may display guarded or defensive behaviors due to unfamiliarity (e.g., language barriers or lack of knowledge of rules and regulations) or in response to the perceived neglect or indifference of the majority society.  These behaviors can, in turm, generate anger and frustration in those who deal with these individuals, thus setting up a vicious cycle of mutual mistrust, which should not be confused with Paranoid Personality Disorder.  Some ethnic groups also display culturally related behaviors that can be misinterpreted as paranoid.
 Paranoid Personality Disorder may be first apparent in childhood and adolescence with solitariness, poor peer relationships, social anxiety, underachievement in school, hypersensitivity, peculiar thoughts and language, and idiosyncratic fantasies.  These children may appear to be "odd" or "eccentric" and attract teasing.  In clinical samples, this disorder appears to be more commonly diagnosed in males.

Prevalence
The prevalence of Paranoid Personality Disorder has been reported to be 0.5%-2.5% in the general population, 10%-30% among those in inpatient psychiatric settings, and 2%-10% among those in outpatient mental health clinics.

Familial Pattern
There is some evidence for an increased prevalence of Paranoid Personality Disorder in relatives of probands with chronic Schizophrenia and for a more specific familial relationship with Delusional Disorder, Persecutory Type.

Differential Diaagnosis
Paranoid Prsonality Disorder can be distinguished from Delusional Disorder, Persecutory Type, Schizophrenia, Paranoid Type, and Mood 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 Paranoid 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 chronic Axis I Psychotic Disorder (e.g., Schizophrenia) that was preceded by Paranoid Personality Disorder, Paranoid Personality Disorder should be recorded on Axis II, followed by "Premorbid" in parentheses.
 Paranoid Personality Disorder must be distinguished from Personality Change Due to a General Medical Condition, in which the traits emerge due to the direct effects of a general medical condition on the central nervous system.  It must also be distinguished from symptoms that may develop in association with chronic substance use (e.g., Cocaine-Related Disorder Not Otherwise Specified).  Finally, it must also be distinguished from paranoid traits associated with the development of physical handicaps (e.g., a hearing impairment)
 Other Personality Disorders may be confused with Paranoid Personality Disorder because they have certain features in common.  it is, therefore, important to distinguish among these disorders based on differences in their characteristic features.  However, if an individual has personality features that meet criteria for one or more Personality Disorders in addition to Paranoid Personality Disorder, all can be diagnosed.  Paranoid Personality Disorder and Schizotypal Personality Disorder share the traits of suspiciousness, interpersonal aloofness, and paranoid ideation, but Schizotypal Personality Disorder also includes symptoms such as magical thinking, unusual perceptual experiences, and odd thinking and speech.  Individuals with behaviors that meet criteria for Schizoid Personality Disorder are often perceived as stange, eccentric, cold, and aloof, but they do not usually have prominent paranoid ideation.  The tendency of individuals with Paranoid Personality Disorder to react to minor stimuli with anger is also seen in Borderline and Histrionic Personality Disorders.  However, these disorders are not necessarily associated with pervasive suspiciousness.  People with Avoidant Personality Disorder may also be reluctant to confide in others, but more because of a 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 due 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.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

301.20  Schizoid Personality Disorder

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 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 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 Mood Disorder With Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder or if it is due to the direct physiological effects of a neurological (e.g., temportal lobe epilepsy) or other general medical condition (Criterion B).

Associated Features and Disorders
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" intheir goals.  Such individuals often react passively to adverse circumstances and have difficulty responding appropriately to important life events.  Because of their lack of social skills and lack of desire for sexual experiences, individuals with this disorder have few friendships, date infrequently, and often do not marry.  Occupational functioning may be impaired, particularly if interpersonal involvement is required, but individuals with this disorder may do well when they work under conditions of social isolation.  Particularly in response to stress, individuals with this disorder may experience very brief psychotic episodes (lasting minutes to hours).  In some instances, Schizoid Personality Disorder may appear as the premorbid antecedent of Delusional Disorder or Schizophrenia.  Individuals with this disorder may sometimes develop Major Depressive Disorder, Schizoid Personality Disorder most often co-occurs with Schizotypal, Paranoid, and Avoidant Personality Disorders.

Specific Culture, Age, and Gender Features
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 be manifested by solitary activities, constricted affect, and other deficits in communication.  Immigrants from other countries are sometimes mistakenly perceived as cold, hostile, or indifferent.
 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.
 Schizoid Personality Disorder is diagnosed slightly more often in males and may cause more impairment in them.

Prevalence
Schizoid Personality Disorder is uncommon in clinical settings.

Familial Pattern
Schizoid Personality Disorder may have increased prevalence in the relatives of individuals with Schizophrenia or Schizotypal Personality Disorder.

Differential Diagnosis
Schizoid Personality Disorder can be distinguished from Delusional Disorder, Schizophrenia, and Mood 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 chronic Axis I Psychotic Disorder (e.g., Schizophrenia) that was preceded by Schizoid Personality Disorder, Schizoid Personality Disorder should be recorded on Axis If followed by "Premorbid" in parentheses.
 There may be great difficulty differentating individuals with Schizoid Personality Disorder from those with milder forms of Autistic Disorder and from those with Asperger’s Disorder.  Milder forms of Autistic Disorder and Asperger’s Disorder are differentiated by more severely impaired social interaction and stereotyped behaviors and interests.
 Schizoid Personality Disorder must be distinguished from Personality Change Due to a General Medical Condition, in which the traits emerge due to the direct effects of a general medical condition on the central nervous system.  It must also be distinguished from symptoms that may develop in association with chronic substance use (e.g., Cocaine-Related Disorder Not Otherwise Specified)
 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 due to fear of being embarrassed or found inadequate and excessive anticipation of rejection.  In contrast, people with Schizoid Personality Disorder have a more pervasive detachment and limited desire for social intimacy.  Individuals with Obsessive-Compulsive Personality Disorder may also show an apparent social detachment stemming from devotion to work and discomfort with emotions, but they do have an underlying capacity for intimacy.
 Individuals who are "loners" may display personality traits that might be considered schizoid.  Only when these traits are inflexible and maladaptive and cause significant functional impairment or subjective distress do they constitute Schizoid Personality Disorder.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

301.22  Schizotypal Personality Disorder

Diagnostic Features
The essential feature of Schizotypal Personality Disorder is a pervasive pattern of social and interpersonal deficits areked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior.  This pattern begins by early adulthood and is present in a variety of contexts.
 Individuals with Schizotypal Personality Disorder often have ideas of reference (i.e., incorrect interpretations of casual incidents and external events as having a particular and unusual meaning specifically for the person) (Criterion A1).  These should be distinguished from delusions of reference, in with 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 taking the dog our for a walk is the direct result to thinking it should be done an hour earlier) or indirectly through compliance with magical rituals (e.g., walking past a specific object three times to avoid a certain harmful outcome).  Perceptual alterations may be present (e.g., sensing that another person is present or hearing a voice murmuring his or her name) (Criterion A3).  Their speech may include unusual or idiosyncratic phrasing and construction.  It is often loose, digressive, or vague, but without actual derailment of 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 person may state that he or the 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 person may avoid eye contract, 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 relatedess as problematic and are uncomfortable relating to other people.  Although they may express unhappiness about their lack of relationships, their behavior suggests a decreased desire for intimate contacts.  As a result, they usually have no or few close friends or confidants other than a first-degree relative (Criterion A8).  They are anxious in social situations, particularly those involving unfamiliar people (Criterion A9).  They will interact with other people 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 familar 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 Mood Disorder With Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder (Criterion B).

Associated Features and Disorders
Individuals with Schizotypal Personality Disorder often seek treatment for the associated symptoms of anxiety, depression, or other dysphoric affects rather than for the personality disorder features per se.  Particularly in response to stress, individuals with this disorder may experience transient psychotic episodes (lasting minutes to hours), although they usually are insufficient in duration to warrant an additional diagnosis such as Brief Psychotic Disorder or Schizophreniform Disorder.  In some cases, clinically significant psychotic symptoms may develop that meet criteria for Brief Psychotic Disorder, Schizophreniform Disorder, Delusional Disorder, or Schizophrenia.  Over half may have a history of at least one Major Depressive Episode.  From 30% to 50% of individuals diagnosed with this disorder have a concurrent diagnosis of Major Depressive Disorder when admitted to a clinical setting.  There is considerable co-occurrence with Schizoid, Paranoid, Avoidant, and Broderline Personality Disorders.

Specific Culture, Age, and Gender Features
Cognitive and perceptual distortions must be evaluated in the context of the individual’s cultural milieu.  Pervasive culturally determined characteristics, particularly those regarding religious beliefs and rituals, can appear to be schizotypal to the uninformed outsider (e.g., voodoo, speaking in tongues, life beyond death, shamanism, mind reading, sixth sense, evil eye, and magical beliefs related to health and illness).
 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.  Schizotypal Personality Disorder may be slightly more common in males.

Prevalence
Schizotypal Personality Disorder has been reported to occur in approximately 3% of the general population.

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.

Familial Pattern
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.

Differential Diagnosis
Schizotypal Personality Disorder can be distinguished from Delusional Disorder, Schizophrenia, and Mood Disorder With Psychotic Features because these disorder 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 chronic Axis I Psychotic Disorder (e.g., Schizophrenia) that was preceded by Schizotypal Personality Disorder, Schizotypal Personality Disorder should be recorded on Axis II followed by "Premorbid" in parentheses.
 There may be great difficulty differentiating children with Schizotypal PersonalityDisorder from the heterogeneous group of solitary, odd children whose behavior is characterized by marked social isolation, eccentricity, or pecliarities of language and whose diagnoses would probably include milder forms of Autistic Disorder, Asperger’s Disorder, and Expressive and Mixed Receptive-Expressive Language  social withdrawal, depressed mood, and Dysthymic or Major Depressive Disorder. In contrast, sustained periods of grandiosity may be associated with a hypomanic mood. Narcissistic  Personality  Disorder is also associated with Anorexia Nervosa and Substance- Related Disorders (especially-related to cocaine). Histrionic, Borderline, Antisocial, and Paranoid Personality  Disorders may be associated with Narcissistic Personality Disorder.

Specific Age and Gender Features
Narcissistic traits  may be particularly common in adolescents and do not necessarily indicate that the individual will go on to have Narcissistic Personality Disorder. Individuals with Narcissistic Personality Disorder may have special difficulties adjusting to the onset of physical and occupational limitations that are inherent in the aging process. Of those diagnosed with Narcissistic  Personality Disorder, 50%-75% are male.

Prevalence
Estimates of prevalence of Narcissistic Personality Disorder range from 2% to 16% in the clinical population and are less than 1% in the general population.

Differential Diagnosis
Other Personality Disorders may be confused with Narcissistic Personality Disorder because they have certain features in  common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features.  However, if an individual has personality features that meet  criteria for one or more Personality Disorders in addition to Narcissistic Personality Disorder. all can be diagnosed. The most useful feature in discriminating Narcissistic Personality Disorder from  Histrionic Antisocial, and Borderline Personality Disorders, whose interactive styles are respectively coquettish, callous, and needy  is the grandiosity characteristic of  Narcissistic Personality Disorder. The relative stability of  self-image as well as the relative lack of self-image as well as  the relative lack of self-destructiveness. impulsivity, and abandonment concerns also help distinguish Narcissistic Personality Disorder from Borderline Personality Disorder. Excessive pride in  achievements, a relative lack of emotional display, and disdain for  others'sensitivities help distinguish Narcissistic Personality Disorder from Histrionic Personality Disorder. Although individuals with Borderline, Histrionic, and Narcissistic Personality Disorders may require much attention, those with Narcissistic Personality Disorder specifically need that attention to be admiring. Individuals with Antisocial and Narcissistic Personality Disorders will share a tendency to be tough-minded, glib, superficial, exploitative, and unempathic. However, Narcissistic Personality  Disorder does not necessarily include characteristics of impulsivity, aggression, and deceit. In addition, individuals with  Antisocial Personality Disorder may not be as needy of the admiration and envy of others, and persons with Narcissistic  Personality Disorder usually lack the history of Conduct  Disorder in childhood or criminal behavior in adulthood. In both Narcissistic Personality Disorder and Obsessive-Compulsive personality Disorder, the individual may profess a commitment to perfectionism and believe that others cannot do things as well. In contrast to  the accompanying self-criticism of those with Obsessive-Compulsive Personality Disorder. individuals with Narcissistic Personality Disorder are more likely to believe that they have achieved perfection. Suspiciousness and social  withdrawal  usually distinguish those with Schizotypal or Paranoid Personality Disorder from those with Narcissistic Personality  Disorder. When these qualities are present in individuals with  Narcissistic Personality Disorder, they derive primarily from fears of having imperfections or flaws revealed. Grandiosity may emerge as part of Manic or Hypomanic Episodes, but the association with mood change or functional impairments helps     distinguish these episodes from Narcissistic Personality Disorder.
  Narcissistic Personality Disorder must be distinguished from Personality Change Due to a General Medical Condition, in  which the traits emerge due to the direct effects of a general medical condition on the central nervous system. It must also be distinguished from symptoms that may develop in association with chronic substance use (e.g.Cocaine-Related Disorder Not Otherwise Specified).  Many highly successful individuals display personality  traits that might be considered narcissistic. Only when these traits are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress do they constitute Narcissistic Personality Disorder.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Cluster C Personality Disorders

301.82  Avoidant Personality Disorder

Diagnostic Features
The essential feature of Avoidant Personality Disorder is a pervasive pattern of social inhibition, feelings of inadequacy,  and hypersensitivity to negative evaluation that begins by early  adulthood and is present in a variety of contexts.
 Individuals with Avoidant Personality Disorder avoid work or school activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection (Criterion 1). Offers of job promotions may be declined because the new responsibilities might result in criticism from  co-workers. These individuals avoid making new friends unless they are certain they will be liked and accepted without criticism (Criterion 2). Until they pass stringent tests proving the contrary, other people are assumed to be critical and disapproving. Individuals with this disorder will not join in group activities unless there are repeated and generous offers of support and nurturance. Interpersonal intimacy is often difficult for these individuals, although they are able to establish intimate relationships when there is assurance of uncritical acceptance. They may act with restraint, have difficulty talking about themselves, and withhold intimate  feelings for fear of being exposed, ridiculed, or shamed  (Criterion 3).
 Because individuals with this disorder are preoccupied  with being criticized or rejected in social situations, they  may have a markedly low threshold for detecting such reactions    (Criterion 4). If someone is even slightly disapproving or critical, they may feel extremely hurt. They tend to be shy,  quiet, inhibited, and "invisible" because of the fear that any     attention would be degrading or rejecting. They expect that no  matter what they say, others will see  it as "wrong," and so  they may say nothing at all. They react strongly to subtle cues that are suggestive of mockery or derision. Despite their longing to be active participants in social life, they fear  placing their welfare in the hands of others.   Individuals with Avoidant Personality Disorder are inhibited in new interpersonal situations because they feel inadequate and  have low self-esteem (Criterion 5). Doubts concerning social     competence and personal appeal become especially manifest in settings involving interactions with strangers. These individuals believe themselves to be socially inept, personally    unappealing, or inferior to others (Criterion 6). They are unusually reluctant to take personal risks or to engage in  any new activities because these may prove embarrassing (Criterion 7). They are prone to exaggerate the potential dangers of ordinary situations, and a restricted lifestyle may result from their need for certainty and security. Someone with  this disorder may cancel a job interview for fear of being embarrassed by not dressing appropriately. Marginal somatic symptoms or other problems may become the reason for avoiding new activities.
 

Associated Features and Disorders
Individuals with Avoidant Personality Disorder often vigilantly  appraise the movements and expressions of those with whom they  come into contact. Their fearful and tense demeanor may elicit ridicule and derision from others, which in turn confirms their self-doubts. They are very anxious about the possibility that they will react to criticism with blushing or crying. They are  described by others as being "shy," "timid," "lonely," and "isolated." The major problems associated with this disorder occur in social and occupational functioning. The low self-esteem and hypersensitivity to rejection are associated with restricted interpersonal contacts. These individuals may become relatively isolated and usually do not have a large social support network that can help them weather crises.  They desire affection and acceptance and may fantasize about idealized relationships with others. The avoidant behaviors can also adversely affect occupational functioning because  these individuals try to avoid the types of social situations  that may be important for meeting the basic demands of the job or for advancement.  Other disorders that are commonly diagnosed with Avoidant Personality Disorder include Mood and Anxiety Disorders  (especially Social Phobia of the Generalized Type). Avoidant Personality Disorder is often diagnosed with Dependent Personality Disorder, because individuals with Avoidant Personality Disorder become very attached to and dependent  on those few other people with whom they are friends. Avoidant Personality Disorder also tends to be diagnosed with Borderline Personality Disorder and with the Cluster A Personality Disorders (i.e., Paranoid, Schizoid, or Schizotypal Personality Disorders).

Specific Culture, Age, and Gender Features
There may be variation in the degree to which different cultural  and ethnic groups regard diffidence and avoidance as appropriate.  Moreover, avoidant behavior may be the result of problems in  acculturation following immigration. This diagnosis  should be used with great caution in children and adolescents for whom shy and avoidant behavior may be developmentally appropriate. Avoidant Personality Disorder appears to be equally frequent in    males and females.
 
 

Prevalence
The prevalence of Avoidant Personality Disorder in the general population is between 0.5% and 1.0%. Avoidant Personality Disorder has been reported to be present in about 10% of    outpatients seen  in mental health clinics.

Course
The avoidant behavior often starts in infancy or childhood with shyness, isolation, and fear of strangers and new situations. Although shyness in childhood is a common precursor of Avoidant Personality Disorder, in most individuals it tends to gradually  dissipate as they get older. In contrast, individuals who go on to develop Avoidant Personality Disorder may become increasingly shy and avoidant during adolescence and early adulthood, when social relationships with new people become especially important. There is some evidence that in adults Avoidant Personality Disorder tends to become less evident or to  remit with age.

Differential Diagnosis
There appears to be a great deal of overlap between Avoidant Personality Disorder and Social Phobia,Generalized Type, so much so that they may be alternative conceptualizations of the same or similar conditions. Avoidance also characterizes both Avoidance Personality Disorder and Panic Disorder With  Agoraphobia, and they often co-occur. The avoidance in Panic Disorder With Agoraphobia typically starts after the onset of Panic Attacks and may vary based on their frequency and intensity. In contrast, the avoidance in Avoidant Personality Disorder to have an early onset, an absence of clear precipitants, and a stable course.
 Other Personality Disorder may be confused with Avoidant Personality Disorder because they have certain features  in common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet  criteria for one or more Personality Disorders in addition to Avoidant Personality Disorder, all can be diagnosed. Both Avoidant Personality Disorder and Dependent Personality Disorder are characterized by feelings of inadequacy, hypersensitivity to criticism, and a need for reassurance Although the primary focus of concern in Avoidant Personality  Disorder is avoidance of humiliation and rejection, in Dependent Personality Disorder the focus is on being taken care of. However, Avoidant Personality Disorder and Dependent Personality  disorder are particularly likely to co-occur. Like Avoidant Personality Disorder, Schizoid Personality Disorder and Schizotypal Personality Disorder are characterized by social isolation. However, individuals with Avoidant Personality Disorder want to have relationships with others and feel their    loneliness deeply, whereas those with Schizoid or Schizotypay Personality Disorder may be content with and even prefer their social isolation. Paranoid Personality Disorder and Avoidant Personality Disorder are both characterized by a reluctance to confide in others. However, in Avoidant Personality Disorder,  this reluctance is due more to a fear of being embarrassed or being found inadequate than to a fear of others' malicious  intent.
 Avoidant Personality Disorder must be distinguished from  Personality Change Due to a General Medical Condition, in which the traits emerge due to the direct effects of a general medical   condition on the central nervous system. It must also be distinguished from symptoms that may develop in association with chronic substance use (e.g., Cocaine-Related Disorder Not Otherwise Specified).
 Many individuals display avoidant personality traits. Only when these traits are inflexible, mmaladaptive, and persisting and cause significant functional impairment or subjective distress do they constitute Avoidant Personality Disorder.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

301.6   Dependent Personality Disorder

Diagnostic Features
The essential Feature of Dependent Personality Disorder is a pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation. This pattern begins by early adulthood and is present in a variety of contexts. The dependent and submissive behaviors are designed to elicit caregiving and arise from self-perception of being unable to function adequately without the help of others.
 Individuals with Dependent Personality Disorder have great difficulty making everyday decisions (e.g., what color shirt to wear to work or whether to carry an umbrella) without an  excessive amount of advice and reassurance from others (Criterion 1).These individuals tend to be passive and to allow other people (often a single other people (often a single other  person) to take the initiative and assume responsibility for  most major areas of their lives (Criterion 2). Adults with this  disorder typically depend on a parent or spouse to decide where they should live, what kind of job they should have, and which  neighbors to befriend. Adolescents with this disorder may allow their parent(s) to decide what they should wear, with whom they  should associate, how they should spend their free time and what  school or college they should attend. This need for others to assume  responsibility goes beyond age-appropriate and  situation-appropriate requests for assistance from others (e.g., the specific needs of children, elderly persons, and handicapped persons). Dependent Personality Disorder may occur in an individual who has a serious general medical condition or  disability, but in such cases the difficulty in taking  responsibility must go beyond what would normally be associated with that condition or disability.
 Because they fear losing support or approval, individuals with Dependent Personality Disorder often have difficulty    expressing disagreement with other people, especially those on whom they are dependent (Criterion 3). These individuals feel so  unable to function alone that they will agree with things that they feel are wrong rather than risk losing the help of those to whom they look for guidance. They do not get appropriately angry at others whose support and nurturance they need for fear of alienating them. If the individual's concerns regarding the  consequences of expressing disagreement are realistic (e.g., realistic fears of retribution from an abusive spouse, the behavior should not be considered to be evidence of Dependent Personality Disorder.
 Individuals with this disorder have difficulty initiating projects or doing things independently (Criterion 4). They lack self-confidence and believe that they need help to begin  and carry through tasks. They will wait for others to start things because they believe that as a rule others can do them better. These individuals are convinced that they are incapable of functioning independently and present themselves as inept and  requiring constant assistance. They are, however, likely to function adequately if given the assurance that someone else is supervising and approving. There may be a fear of becoming or appearing to be more competent. because they may believe that this will lead to abandonment. Because they rely on others to handle their problems, they often do not learn the skills of independent living. thus perpetuating dependency.
 Individuals with Dependent Personality Disorder may go to excessive lengths to obtain nurturance and support from others, even to the point of volunteering for unpleasant tasks if such behavior will bring the care they need (Criterion 5). They are willing to submit to what others want, even if the demands are unreasonable. Their need to maintain an important bond will often result in imbalanced or distorted relationships. They may make extraordinary self-sacrifices or tolerate verbal, physical, or tolerate verbal, physical, or sexual abuse. (It should be noted that this behavior should be considered evidence of Dependent Personality Disorder only when it can clearly be established that other options are available to the individual). Individuals with this disorder feel uncomfortable or helpless when alone, because of their exaggerated fears of being to care for themselves (Criterion 6). They will "tag along" with important others just to avoid be alone, even if they are not interested or involved in what is happening.
 When a close relationship ends (e.g., a breakup with a lover; the death of a caregiver), individuals with Dependent Personality Disorder may urgently seek another relationship to provide the care and support they need (Criterion 7). Their belief that they are unable to function in the absence of a close relationship motivates these individuals to become quickly and indiscriminately attached to another person. Individuals with this disorder are often preoccupied with fears of being left to care for themselves (Criterion 8). They see themselves as so totally dependent on the advice and help of an important other person that they worry about being abandoned by that person when there are no grounds to justify to justify such fears. To be considered as evidence of this criterion, the fears must be excessive and unrealistic. For example, an elderly man with  cancer who moves into his son's household for care is exhibiting dependent behavior that is appropriate given this person's life circumstances.

Associated Features and Disorders
Individuals with Dependent Personality Disorder are often characterized pessimism and self-doubt, tend to belittle their abilities and assets, and may constantly refer to themselves as    "stupid." They take criticism and disapproval as proof of their worthlessness and lose faith in themselves. They may seek overprotection and dominance from others. Occupational     functioning may be impaired if independent initiative is required. They may avoid positions of responsibility and become anxious when faced with decisions. Social relations tend to be    limited to those few people on whom  the individual is dependent. There may be an increased risk of Mood Disorder, Anxiety Disorders, Anxiety Disorders, and Adjustment Disorder. Dependent Personality Disorder often co-occurs with other Personality Disorders, especially Borderline, Avoidant, and Histrionic Personality Disorders. Chronic physical illness or Separation Anxiety Disorder in childhood or adolescence may predispose the     individual to the development of this disorder.

Specific Culture, Age, and Gender Features
The degree to which dependent behaviors are considered to be appropriate varies substantially across different age and  sociocultural groups. Age and cultural factors need to be   considered in evaluating the diagnostic threshold of each  criterion. Dependent behavior should be considered  characteristic of the disorder only when it is clearly in excess of the individual's cultural norms or reflects unrealistic  concerns. An emphasis an passivity, politeness, and deferential  treatment is characteristic of some societies and may be misinterpreted as traits of Dependent Personality Disorder. Similarly, societies may differentially foster and discourage dependent behavior in males and females. This diagnosis should be used with great caution, if at all, in children and adolescents, for whom dependent behavior may be developmentally appropriate. In clinical settings, this disorder has been diagnosed more frequently in females; however, the sex ratio of this disorder is not significantly different than the sex ratio of females within the respective clinical setting. Moreover, some  studies using structured assessments report similar prevalence rates among males and females.

Prevalence
Dependent Personality Disorder is among the most frequently reported Personality Disorder encountered in mental health  clinics.

Differential Diagnosis
Dependent Personality Disorder must be distinguished from dependency arising as a consequence of Axis I disorders (e.g.,Mood Disorders, Panic Disorder, and Agoraphobia) and as a result of  general medical conditions. Dependent Personality Disorder has an early onset, chronic course, and a pattern of behavior that does not occur exclusively during  an Axis I or Axis III disorder.
 Other Personality Disorders may be confused with Dependent Personality Disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more Personality Disorders in addition to Dependent Personality Disorder, all can be diagnosed. Although many Personality Disorders characterized by dependent features, Dependent Personality Disorder can be distinguished by its predominantly  submissive, reactive, and clinging behavior. Both Dependent Personality Disorder and Borderline Personality Disorder are  characterized by fear of abandonment; however, the individual with Borderline Personality Disorder reacts to abandonment with feelings of emotional emptiness, rage, and demands, whereas the individual with Dependent Personality Disorder reacts with increasing appeasement and submissiveness and urgently seeks a replacement relationship to provide caregiving and support. Borderline Personality Disorder can further be distinguished from Dependent Personality Disorder by a typical pattern of unstable and intense relationships. Individuals with  Histrionic Personality Disorder, like those with Dependent Personality Disorder, have a strong need for reassurance and approval  and may appear childlike and clinging. However, unlike  Dependent Personality Disorder, which is characterized by self-effacing and docile behavior, Histrionic Personality  Disorder is characterized by gregarious flamboyance with  active demands for attention. Both Dependent Personality Disorder and Avoidant Personality Disorder are characterized  by feelings of inadequacy, hypersensitivity to criticism, and a need for reassurance; however, individuals with Avoidant Personality Disorder have such a strong fear of humiliation  and rejection that they withdraw until they are certain they will be accepted. In contrast, individuals with Dependent Personality Disorder have a pattern of seeking and maintaining  connections to important others, rather than avoiding and withdrawing from relationships.
 Dependent Personality Disorder must be distinguished from  Personality Change Due to a General Medical Condition, in which  the traits emerge due to the direct effects of a general medical  condition on the central nervous system. It must also be distinguished from symptoms that may develop in association with  chronic substance use (e.g.,Cocaine-Related Disorder Not Otherwise Specified).
 Many individuals display dependent personality traits. Only when these traits are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress do they constitute Dependent Personality Disorder.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

301.4  Obsessive-Compulsive Personality Disorder

Diagnostic Features
The essential feature of Oobsessive-Compulsive Personality Disorder is a preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. This pattern begins by early adulthood and is present in a variety of contexts.
           Individuals with Obsessive-Compulsive Personality Disorder  attempt to maintain a sense of control through painstaking  attention to rules, trivial details, procedures, lists, schedules, or form to the extent that the major point of the activity is lost (Criterion 1). They are excessively careful and prone to repetition, paying extraordinary attention to detail    and repeatedly checking for possible mistakes. They are oblivious to the fact that other people tend to become very annoyed at the delays and inconveniences that result from this    behavior. For example, when such individuals misplace a list of things to be done, they will spend an inordinate amount of time looking for the list rather than spending a few moments re-creating it from memory and proceeding to accomplish the tasks. Time is poorly allocated, the most important tasks being left to the last moment. The perfectionism and self-imposed high  standards of performance cause significant dysfunction and distress in these individuals. They may become so involved in making every detail of a project absolutely perfect that the project in never finished (Criterion 2). For example, the   completion of a written report is delayed by numerous time-consuming rewrites that all come up short of "perfection." Deadlines are missed, and aspects of the individual's life that are not the current focus of activity may fall into disarray.
 Individuals with Obsessive-Compulsive Personality Disorder display excessive devotion to work and productivity to the exclusion of leisure activities and friendships (Criterion 3). This behavior is not accounted for by economic necessity. They often feel that they do not have time to take an evening or a  weekend day off to go on an outing or to just relax. They may keep postponing a pleasurable activity, such as a vacation, so that it may never occur. When they do take time for leisure activities or vacations, they are very uncomfortable unless  they have taken along something to work on so they do not "waste time." There may be a great concentration on household chores (e.g., repeated excessive cleaning so that "one could eat off the floor"). If they spend time with friends, it is likely to be in some kind of formally organized activity (e.g., sports). Hobbies or recreational activities are approached as serious tasks requiring careful organization and hard work to  master. The emphasis is on perfect performance. These individuals turn play into a structured task (e.g., correcting an infant for not putting rings on the post in the right order; telling a toddler to ride his or her tricycle in a straight line; turning a baseball game into a harsh "lesson").
        Individuals with Obsessive-Compulsive Personality Disorder may be excessively conscientious, scrupulous, and inflexible about matters of morality, ethics, or values (Criterion 4).  They may force themselves and others to follow rigid moral principles and very strict standards of performance. They may also be mercilessly self-critical about their own mistakes.   Individuals with this disorder are rigidly deferential to authority and rules and insist on quite literal compliance, with no rule bending for extenuating circumstances. For example, the individual will not lend a quarter to a friend who needs one to make a telephone call, because "neither a borrower or lender be" or because it would be "bad" for the person's character. These qualities should not be accounted for by the individual's    cultural or religious identification.
 Individuals with this disorder may be unable to discard worn-out or worthless objects, even when they have no sentimental value (Criterion 5). Often these individuals will admit to being "pack rats." They regard discarding objects as wasteful because "you never know when you might needs something" and will become upset if someone tries to get rid of the things they have saved. Their spouses or roommates may complain about the amount of space taken up by old parts, magazines, broken appliances, and so on.
    Individuals with Obsessive-Compulsive Personality Disorder are reluctant to delegate tasks or to work with others (Criterion 6). They stubbornly and unreasonably insist that everything be done their way and that people conform to their way of doing things. They often give very detailed instructions about how things should be done (e.g., there is one and only one way to mow the lawn, wash the dishes, build a doghouse) and are   surprised and irritated if others suggest creative alternatives.  At other times they may reject offers of help even when behind schedule because they believe no one else can do it right.
 Individuals with this disorder may be miserly and stingy and maintain a standard of living far below what they can afford, believing that spending must be tightly controlled to    provide for future catastrophes (Criterion 7). Individuals with Obsessive-Compulsive Personality Disorder are characterized by rigidity and stubbornness (Criterion 8). They are so concerned about having done the one "correct" way that they have trouble going along with anyone else's ideas. These individuals plan ahead in meticulous detail and are unwilling to consider  changes. Totally wrapped up in their own perspective, they have difficulty acknowledging the viewpoints of others. Friends and colleagues may become frustrated by this constant rigidity.  Even when individuals with Obsessive-Compulsive Personality   Disorder recognize that it may be in their interest to compromise, they may stubbornly refuse to do so, arguing that it is "the principle of the thing."

Associated Features and Disorders
When rules and established procedures do not dictate the correct answer, decision making may become a time-consuming, often painful process. Individuals with Obsessive-Compulsive Personality Disorder may have such difficulty deciding which tasks take priority or what is the best way of doing some particular task that they may new never get started on anything. Thy are prone to become upset or angry in situations in which  they are not able to maintain control or their physical or interpersonal environment, although the anger is typically not  expessed directly. For example, a person may be angry when service in a restaurant is poor, but instead of complaining to the management,the individual ruminates about how much to leave as a tip. On other occasions, anger may be expressed with righteous indignation over a seemingly minor matter. People with this disorder may be especially attentive to their relative status in dominance-submission relationships and may display  excessive deference to an authority they respect and excessive resistance to authority that they do not respect.
 Individuals with this disorder usually express affection in a highly controlled or stilted fashion and may be very uncomfortable in the presence of others who are emotionally     expressive. Their everyday relationships have a formal and  serious quality, and they may be stiff in ssituations in which others smile and be happy (e.g., greeting a lover at the airpot). They carefully hold themselves back until they are sure that whatever they say will be perfect. They may be preoccupied with logic and intellect, and intolerant of affective behaviorin others. They  often have difficulty expressing tender feelings, rarely paying compliments.  Individuals with this disorder may experience occupational difficulties and distress, particularly when confronted with new situations that demand flexibility and compromise.
 Although some studies suggest an association with Obsessive-Compulsive Disorder (included in the "Anxiety Disorders" section, p. 417), it appears that the majority of individuals with Obsesseve-Compulsive Disorder do not have a pattern of behavior that meets criteria for Obsessive-compulsive Personality Disorder. Many of the features of     Obsessiv-Compulsive Personality Disorder overlap with "type A" personality characteristics (e.g., hostility, competitiveness, and time urgency), and these features may be present in people  at risk for myocardial infarction. There may be an association between Obsessive-Compulsive Personality Disorder and Mood and  Anxiety Disorders.

Specific Culture and Gender Features
In assessing an individual for Obsessive-Compulsive Personality Disorder, the clinician should not inculude those behaviors that reflect habits, customs, or interpersonal styles that are culturally sanctioned by the individual's reference group. Certain cultures place substantial emphasis on work and  productivity; the resulting behaviors in members of those    societies need not be considered indications of Obsessive-Compulsive Personality Disorder. In systematic studies, the disorder appears to be diagnosed about twice as often among males.

Prevalence
Studies that have used systematic assessment suggest prevalence estimates of Obsessive-ompulsive Personality Disorder of about 1% in community samples and about 3%-10% in individuals  presenting to mental health clinics.

Differential Diagnosis
Despite the similarity in names, Obsessive-Compulsive Disorder is usually easily distinguished from Obsessive-Compulsive Personality Disorder by the presence of true obsessions and compulsions. A diagnosis of Obsessive-compulsive Disorder should be considered especially when hoarding is extreme (e.g. accumulated stacks of worthless objects present at fire hazard and make it difficult for others to walk through the house). When criteria for both disorders are met, both diagnoses  should be recorded.
 Other Personality Disorders may be confused with Obsessive-Compulsive Personality Disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more      Personality Disorder, Disorder, all can be diagnosed. Individuals with  Narcissistic Personality Disorder may also profess a commitment to perfectionism and believe that others     cannot do things as well, but these individuals are more likely to believe that they have achieved perfection, whereas those with Obsessive-Compulsive Personality Disorder are usually self-critical. Individuals with Narcissistic or Antisocial Personality Disorder lack generosity but will indulge themselves, whereas those with Obsessive-Compulsive Personality Disorder adopt a miserly spending style toward both self and others. Both Schizoid Personality Disorder and Obsessive-Compulsive Personality Disorder may be characterized by an apparent formality and social detachment. In Obsessive-Compulsive Personality Disorder, this stems from discomfort with emotions and excessive devotion to work, whereas in Schizoid Pesonality Disorder there is a fundamental lack of  capacity for intimacy.
 Obessive-Compulsive Personality Disorder must be distinguished from Personality Change Due to a General  Medical  Condition, in which the traits emerge due  to the direct effects of a general medical medical condition on the central nervous system. It must also be distinguished from symptoms that may  develop in association with chronic substance use(e.g.,Cocaine-Related Disorder Not Otherwise Specified).
 Obessive-compulsive personality traits in moderation may be especially adaptive, partcularly in situations that reward high  performance. Only when these traits are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress do they constitute Obsessive-Compulsive Personality Disorder.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

301.9  Personality Disorder Not Otherwise Specified

This category is for disorders of personality functionning that do not meet criteria for any specific Personality Disorder. An example is the presence of features of more than one specific Personality Disorder that do not meet full criteria for any one Personality Disorder ("mixed personality"), but that together cause clinically significant distress or impairment in one or more important areas of functioning (e.g., social or occupational). This category can also be used when the clinician judges that a specific Personality Disorder that is not included  in the Classification is appropriate. Examples include depressive personality disorder and passive-aggressive personality disorder (see p. 732 and p. 733, respectively, for  suggested research criteria).