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This chapter begins with a general definition of personality disorder that applies to each of
the 10 specific personality disorders. A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the norms and expectations of the
individual’s culture, is pervasive and inflexible, has an onset in adolescence or early
adulthood, is stable over time, and leads to distress or impairment.
With any ongoing review process, especially one of this complexity, different viewpoints
emerge, and an effort was made to accommodate them. Thus, personality disorders are
included in both Sections II and III. The material in Section II represents an update of text
associated with the same criteria found in DSM-5 (which were carried over from DSM-IV-
TR), whereas Section III includes the proposed model for personality disorder diagnosis
and conceptualization developed by the DSM-5 Personality and Personality Disorders
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Work Group. As this field evolves, it is hoped that both versions will serve clinical practice
and research initiatives, respectively.
The following personality disorders are included in this chapter.
Paranoid personality disorder is a pattern of distrust and suspiciousness such that others’ motives are interpreted as malevolent.
Schizoid personality disorder is a pattern of detachment from social
relationships and a restricted range of emotional expression.
Schizotypal personality disorder is a pattern of acute discomfort in close
relationships, cognitive or perceptual distortions, and eccentricities of behavior.
Antisocial personality disorder is a pattern of disregard for, and violation of, the
rights of others, criminality, impulsivity, and a failure to learn from experience.
Borderline personality disorder is a pattern of instability in interpersonal
relationships, self-image, and affects, and marked impulsivity.
Histrionic personality disorder is a pattern of excessive emotionality and attention seeking.
Narcissistic personality disorder is a pattern of grandiosity, need for admiration,
and lack of empathy.
Avoidant personality disorder is a pattern of social inhibition, feelings of
inadequacy, and hypersensitivity to negative evaluation.
Dependent personality disorder is a pattern of submissive and clinging behavior
related to an excessive need to be taken care of.
Obsessive-compulsive personality disorder is a pattern of preoccupation with
orderliness, perfectionism, and control.
Personality change due to another medical condition is a persistent
personality disturbance that is judged to be the direct pathophysiological consequence
of another medical condition (e.g., frontal lobe lesion).
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Other specified personality disorder is a category provided for two situations: 1)
the individual’s personality pattern meets the general criteria for a personality
disorder, and traits of several different personality disorders are present, but the
criteria for any specific personality disorder are not met; or 2) the individual’s
personality pattern meets the general criteria for a personality disorder, but the
individual is considered to have a personality disorder that is not included in the
DSM-5 classification (e.g., passive-aggressive personality disorder). Unspecified
personality disorder is for presentations in which symptoms characteristic of a personality disorder are present but there is insufficient information to make a more
specific diagnosis.
The personality disorders are grouped into three clusters based on descriptive similarities.
Cluster A includes paranoid, schizoid, and schizotypal personality disorders. Individuals
with these disorders often appear odd or eccentric. Cluster B includes antisocial,
borderline, histrionic, and narcissistic personality disorders. Individuals with these
disorders often appear dramatic, emotional, or erratic. Cluster C includes avoidant,
dependent, and obsessive-compulsive personality disorders. Individuals with these
disorders often appear anxious or fearful. It should be noted that this clustering system,
although useful in some research and educational situations, has serious limitations and
has not been consistently validated. For instance, two or more disorders from different
clusters, or traits from several of them, can often co-occur and vary in intensity and
pervasiveness.
A review of epidemiological studies from several countries found a median prevalence of
3.6% for disorders in Cluster A, 4.5% for Cluster B, 2.8% for Cluster C, and 10.5% for any
personality disorder (Huang et al. 2009; Morgan and Zimmerman 2018). Prevalence
appears to vary across countries and by ethnicity, raising questions about true cross-
cultural variation and about the impact of diverse definitions and diagnostic instruments
on prevalence assessments (McGilloway et al. 2010; Tyrer et al. 2010).
Dimensional Models for Personality Disorders
The diagnostic approach used in this manual represents the categorical perspective that
personality disorders are qualitatively distinct clinical syndromes. An alternative to the
categorical approach is the dimensional perspective that personality disorders represent
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maladaptive variants of personality traits that merge imperceptibly into normality and into
one another. See Section III for a full description of a dimensional model for personality
disorders. The DSM-5 personality disorder clusters (i.e., odd-eccentric, dramatic-
emotional, and anxious-fearful) may also be viewed as dimensions representing spectra of
personality dysfunction on a continuum with other mental disorders. The alternative
dimensional models have much in common and together appear to cover the important
areas of personality dysfunction. Their integration, clinical utility, and relationship with the
personality disorder diagnostic categories and various aspects of personality dysfunction
continue to be under active investigation. This includes research on whether the
dimensional model can clarify the cross-cultural prevalence variations seen with the
categorical model (Alarcón et al. 1998; McGilloway et al. 2010; Tyrer et al. 2010).
References: Dimensional Models for Personality Disorders
Alarcón RD, Foulks EF, Vakkur M: Personality Disorders and Culture: Clinical and
Conceptual Interactions. New York, Wiley, 1998
Huang Y, Kotov R, de Girolamo G, et al: DSM-IV personality disorders in the WHO World
Mental Health Surveys. Br J Psychiatry 195(1):46–53, 2009
McGilloway A, Hall RE, Lee T, Bhui KS: A systematic review of personality disorder, race
and ethnicity: prevalence, aetiology and treatment. BMC Psychiatry 10:33, 2010
Morgan TA, Zimmerman M: Epidemiology of personality disorders, in Handbook of
Personality Disorders: Theory, Research, and Treatment, 2nd Edition. Edited by Livesley
WJ, Larstone R. New York, Guilford, 2018, pp 173–196
Tyrer P, Mulder R, Crawford M, et al: Personality disorder: a new global perspective.
World Psychiatry 9(1):56–60, 2010
General Personality Disorder
Criteria
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A. An enduring pattern of inner experience and behavior that deviates markedly
from the expectations of the individual’s culture. This pattern is manifested in two
(or more) of the following areas:
1. Cognition (i.e., ways of perceiving and interpreting self, other people, and
events).
2. Affectivity (i.e., the range, intensity, lability, and appropriateness of
emotional response).
3. Interpersonal functioning.
4. Impulse control.
B. The enduring pattern is inflexible and pervasive across a broad range of personal
and social situations.
C. The enduring pattern leads to clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
D. The pattern is stable and of long duration, and its onset can be traced back at least
to adolescence or early adulthood.
E. The enduring pattern is not better explained as a manifestation or consequence of
another mental disorder.
F. The enduring pattern is not attributable to the physiological effects of a substance
(e.g., a drug of abuse, a medication) or another medical condition (e.g., head
trauma).
Diagnostic Features
Personality traits are enduring patterns of perceiving, relating to, and thinking about the
environment and oneself that are exhibited in a wide range of social and personal contexts.
Only when personality traits are inflexible and maladaptive and cause significant functional
impairment or subjective distress do they constitute personality disorders. The essential
feature of a personality disorder is an enduring pattern of inner experience and behavior
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that deviates markedly from the norms and expectations of the individual’s culture and is
manifested in at least two of the following areas: cognition, affectivity, interpersonal
functioning, or impulse control (Criterion A). This enduring pattern is inflexible and
pervasive across a broad range of personal and social situations (Criterion B) and leads to
clinically significant distress or impairment in social, occupational, or other important
areas of functioning (Criterion C). The pattern is stable and of long duration, and its onset
can be traced back at least to adolescence or early adulthood (Criterion D). The pattern is
not better explained as a manifestation or consequence of another mental disorder
(Criterion E) and is not attributable to the physiological effects of a substance (e.g., a drug
of abuse, a medication, exposure to a toxin) or another medical condition (e.g., head
trauma) (Criterion F). Specific diagnostic criteria are also provided for each of the
personality disorders included in this chapter.
The diagnosis of personality disorders requires an evaluation of the individual’s long-term
patterns of functioning, and the particular personality features must be evident by early
adulthood. The personality traits that define these disorders must also be distinguished
from characteristics that emerge in response to specific situational stressors or more
transient mental states (e.g., bipolar, depressive, or anxiety disorders; substance
intoxication). The clinician should assess the stability of personality traits over time and
across different situations. Although a single interview with the individual is sometimes
sufficient for making the diagnosis, it is often necessary to conduct more than one
interview and to space these over time. Assessment can also be complicated by the fact that
the characteristics that define a personality disorder may not be considered problematic by
the individual (i.e., the traits are often ego-syntonic). To help overcome this difficulty,
supplementary information from other informants may be helpful.
Development and Course
The features of a personality disorder usually become recognizable during adolescence or
early adult life. By definition, a personality disorder is an enduring pattern of thinking,
feeling, and behaving that is relatively stable over time. Some types of personality disorder
(notably, antisocial and borderline personality disorders) tend to become less evident or to
remit with age, whereas this appears to be less true for some other types (e.g., obsessive-
compulsive and schizotypal personality disorders).
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Personality disorder categories may be applied with children or adolescents in those
relatively unusual instances in which the individual’s particular maladaptive personality
traits appear to be pervasive, persistent, and unlikely to be limited to a particular
developmental stage or attributable to another mental disorder. It should be recognized
that the traits of a personality disorder that appear in childhood will often not persist
unchanged into adult life. For a personality disorder to be diagnosed in an individual
younger than 18 years, the features must have been present for at least 1 year. The one
exception to this is antisocial personality disorder, which cannot be diagnosed in
individuals younger than 18 years. Although, by definition, a personality disorder requires
an onset no later than early adulthood, individuals may not come to clinical attention until
relatively late in life. A personality disorder may be exacerbated following the loss of
significant supporting persons (e.g., a spouse) or previously stabilizing social situations
(e.g., a job). However, the development of a change in personality in middle adulthood or
later life warrants a thorough evaluation to determine the possible presence of a
personality change due to another medical condition or an unrecognized substance use
disorder.
Culture-Related Diagnostic Issues
Core aspects of personality like emotion regulation and interpersonal functioning are
influenced by culture, which also provides means of protection and assimilation and norms
for acceptance and denunciation of specific behaviors and personality traits (Ronningstam
et al. 2018). Judgments about personality functioning must take into account the
individual’s ethnic, cultural, and social background. Personality disorders should not be
confused with problems associated with acculturation following migration or with the
expression of habits, customs, or religious and political values based on the individual’s
cultural background or context. Behavioral patterns that appear to be rigid and
dysfunctional aspects of personality disorder may reflect instead adaptive responses to
cultural constraints (Balaratnasingam and Janca 2017; Fang et al. 2016; Ronningstam et al.
2018; Ryder et al. 2014). For example, reliance on an abusive relationship in a small
community where divorce is proscribed may not reflect pathological dependence;
conscientious political protest that puts friends and family members at risk with authorities
or in conflict with legal norms does not necessarily reflect pathological callousness (Ryder
et al. 2014). There are marked variations in the recognition and diagnosis of personality
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disorders across cultural, ethnic, and racialized groups (Alarcón et al. 1998; McGilloway et
al. 2010; Tyrer et al. 2010). Accuracy of diagnosis can be enhanced by attention to
culturally patterned conceptions of self and attachment, assessment biases resulting from
clinicians’ own cultural backgrounds or use of diagnostic instruments that are not normed
to the population being assessed, and the impact of social determinants such as poverty,
acculturative stress, racism, and discrimination on feelings, cognitions, and
behaviors (Iacovino et al. 2014; Raza et al. 2014; Ryder et al. 2014). It is useful for the
clinician, especially when evaluating someone from a different background, to obtain
additional information from informants who are familiar with the person’s cultural
background.
Sex- and Gender-Related Diagnostic Issues
Certain personality disorders (e.g., antisocial personality disorder) are diagnosed more
frequently in men. Others (e.g., borderline, histrionic, and dependent personality
disorders) are diagnosed more frequently in women; however, in the case of borderline
personality disorder, this may be due to higher help-seeking among women. Nonetheless,
clinicians must be cautious not to overdiagnose or underdiagnose certain personality
disorders in women or in men because of social stereotypes about typical gender roles and
behaviors. There is currently insufficient evidence on differences between cis- and
transgender individuals with respect to the epidemiology or clinical presentations of
personality disorders to draw meaningful conclusions.
Differential Diagnosis
Other mental disorders and personality traits
Many of the specific criteria for the personality disorders describe features (e.g.,
suspiciousness, dependency, insensitivity) that are also characteristic of episodes of other
mental disorders. A personality disorder should be diagnosed only when the defining
characteristics appeared before early adulthood, are typical of the individual’s long-term
functioning, and do not occur exclusively during an episode of another mental disorder. It
may be particularly difficult (and not particularly useful) to distinguish personality
disorders from persistent mental disorders such as persistent depressive disorder that have
an early onset and an enduring, relatively stable course. Some personality disorders may
have a “spectrum” relationship to other mental disorders (e.g., schizotypal personality
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disorder with schizophrenia; avoidant personality disorder with social anxiety disorder)
based on phenomenological or biological similarities or familial aggregation.
Personality disorders must be distinguished from personality traits that do not reach the
threshold for a personality disorder. Personality traits are diagnosed as a personality
disorder only when they are inflexible, maladaptive, and persisting and cause significant
functional impairment or subjective distress.
Psychotic disorders
For the three personality disorders that may be related to the psychotic disorders (i.e.,
paranoid, schizoid, and schizotypal), there is an exclusion criterion stating that the pattern
of behavior must not have occurred exclusively during the course of schizophrenia, a
bipolar or depressive disorder with psychotic features, or another psychotic disorder. When
an individual has a persistent mental disorder (e.g., schizophrenia) that was preceded by a
preexisting personality disorder, the personality disorder should also be recorded, followed
by “premorbid” in parentheses.
Anxiety and depressive disorders
The clinician must be cautious in diagnosing personality disorders during an episode of a
depressive disorder or an anxiety disorder, because these conditions may have cross-
sectional symptom features that mimic personality traits and may make it more difficult to
evaluate retrospectively the individual’s long-term patterns of functioning.
Posttraumatic stress disorder
When personality changes emerge and persist after an individual has been exposed to
extreme stress, a diagnosis of posttraumatic stress disorder should be considered.
Substance use disorders
When an individual has a substance use disorder, it is important not to make a personality
disorder diagnosis based solely on behaviors that are consequences of substance
intoxication or withdrawal or that are associated with activities in the service of sustaining
substance use (e.g., antisocial behavior).
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Personality change due to another medical condition
When enduring changes in personality arise as a result of the physiological effects of
another medical condition (e.g., brain tumor), a diagnosis of personality change due to
another medical condition should be considered.
References: General Personality Disorder
Alarcón RD, Foulks EF, Vakkur M: Personality Disorders and Culture: Clinical and
Conceptual Interactions. New York, Wiley, 1998
Balaratnasingam S, Janca A: Culture and personality disorder: a focus on indigenous
Australians. Curr Opin Psychiatry 30(1):31–35, 2017
Fang K, Friedlander M, Pieterse AL: Contributions of acculturation, enculturation,
discrimination, and personality traits to social anxiety among Chinese immigrants: a
context-specific assessment. Culture Divers Ethnic Minor Psychol 22(1):58–68, 2016
Iacovino JM, Jackson JJ, Oltmanns TF: The relative impact of socioeconomic status and
childhood trauma on Black-White differences in paranoid personality disorder symptoms.
J Abnorm Psychol 123(1):225–230, 2014
McGilloway A, Hall RE, Lee T, Bhui KS: A systematic review of personality disorder, race
and ethnicity: prevalence, aetiology and treatment. BMC Psychiatry 10:33, 2010
Raza GT, DeMarce JM, Lash SJ, Parker JD: Paranoid personality disorder in the United
States: the role of race, illicit drug use, and income. J Ethn Subst Abuse 13(3):247–257,
2014
Ronningstam EF, Keng S-L, Ridolfi ME et al. Cultural aspects in symptomatology,
assessment, and treatment of personality disorders. Curr Psychiatry Rep 20(4):22, 2018
29582187
Ryder AG, Dere J, Sun J, Chentsova-Dutton YE: The cultural shaping of personality
disorder, in APA Handbook of Multicultural Psychology. Edited by Leong FTL, Comas-
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(F60.0)
Diaz L, Hall GCN, et al. Washington, DC, American Psychological Association, 2014, pp
307–328
Tyrer P, Mulder R, Crawford M, et al: Personality disorder: a new global perspective.
World Psychiatry 9(1):56–60, 2010
Cluster A Personality Disorders
Paranoid Personality Disorder
Diagnostic Criteria
A. A pervasive distrust and suspiciousness of others such that their motives are
interpreted as malevolent, beginning by early adulthood and present in a variety
of contexts, as indicated by four (or more) of the following:
1. Suspects, without sufficient basis, that others are exploiting, harming, or
deceiving him or her.
2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness
of friends or associates.
3. Is reluctant to confide in others because of unwarranted fear that the
information will be used maliciously against him or her.
4. Reads hidden demeaning or threatening meanings into benign remarks or
events.
5. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights).
6. Perceives attacks on his or her character or reputation that are not apparent
to others and is quick to react angrily or to counterattack.
7. Has recurrent suspicions, without justification, regarding fidelity of spouse
or sexual partner.
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B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder
or depressive disorder with psychotic features, or another psychotic disorder and
is not attributable to the physiological effects of another medical condition.
Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,” i.e.,
“paranoid personality disorder (premorbid).”
Diagnostic Features
The essential feature of paranoid personality disorder is a pattern of pervasive distrust and
suspiciousness of others such that their motives are interpreted as malevolent. This pattern
begins by early adulthood and is present in a variety of contexts.
Individuals with this disorder assume that other people will exploit, harm, or deceive them,
even if no evidence exists to support this expectation (Criterion A1). They suspect on the
basis of little or no evidence that others are plotting against them and may attack them
suddenly, at any time and without reason. They often feel that they have been deeply and
irreversibly injured by another person or persons even when there is no objective evidence
for this. They are preoccupied with unjustified doubts about the loyalty or trustworthiness
of their friends and associates, whose actions are minutely scrutinized for evidence of
hostile intentions (Criterion A2). Any perceived deviation from trustworthiness or loyalty
serves to support their underlying assumptions. They are so amazed when a friend or
associate shows loyalty that they cannot trust or believe it. If they get into trouble, they
expect that friends and associates will either attack or ignore them.
Individuals with paranoid personality disorder are reluctant to confide in or become close
to others because they fear that the information they share will be used against them
(Criterion A3). They may refuse to answer personal questions, saying that the information
is “nobody’s business.” They read hidden meanings that are demeaning and threatening
into benign remarks or events (Criterion A4). For example, an individual with this disorder
may misinterpret an honest mistake by a store clerk as a deliberate attempt to shortchange,
or view a casual humorous remark by a coworker as a serious character attack.
Compliments are often misinterpreted (e.g., a compliment on a new acquisition is
misinterpreted as a criticism for selfishness; a compliment on an accomplishment is
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misinterpreted as an attempt to coerce more and better performance). They may view an
offer of help as a criticism that they are not doing well enough on their own.
Individuals with this disorder persistently bear grudges and are unwilling to forgive the
insults, injuries, or slights that they think they have received (Criterion A5). Minor slights
arouse major hostility, and the hostile feelings persist for a long time. Because they are
constantly vigilant to the harmful intentions of others, they very often feel that their
character or reputation has been attacked or that they have been slighted in some other
way. They are quick to counterattack and react with anger to perceived insults (Criterion
A6). Individuals with this disorder may be pathologically jealous, often suspecting that
their spouse or sexual partner is unfaithful without any adequate justification (Criterion
A7). They may gather trivial and circumstantial “evidence” to support their jealous beliefs.
They want to maintain complete control of intimate relationships to avoid being betrayed
and may constantly question and challenge the whereabouts, actions, intentions, and
fidelity of their spouse or partner.
Paranoid personality disorder should not be diagnosed if the pattern of behavior occurs
exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder
with psychotic features, or another psychotic disorder, or if it is attributable to the
physiological effects of a neurological (e.g., temporal lobe epilepsy) or another medical
condition (Criterion B).
Associated Features
Individuals with paranoid personality disorder are generally difficult to get along with and
often have problems with close relationships. Their excessive suspiciousness and hostility
may be expressed in overt argumentativeness, in recurrent complaining, or by hostile
aloofness. They display a labile range of affect, with hostile, stubborn, and sarcastic
expressions predominating. Their combative and suspicious nature may elicit a hostile
response in others, which then serves to confirm their original expectations.
Because individuals with paranoid personality disorder lack trust in others, they need to
have a high degree of control over those around them. They are often rigid, critical of
others, and unable to collaborate, although they have great difficulty accepting criticism
themselves. They may blame others for their own shortcomings. Because of their quickness
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to counterattack in response to the threats they perceive around them, they may be litigious
and frequently become involved in legal disputes. Individuals with this disorder seek to
confirm their preconceived negative notions regarding people or situations they encounter,
attributing malevolent motivations to others that are projections of their own fears. They
may exhibit thinly hidden, unrealistic grandiose fantasies, are often attuned to issues of
power and rank, and tend to develop negative stereotypes of others, particularly those from
population groups distinct from their own. Attracted by simplistic formulations of the
world, they are often wary of ambiguous situations. They may be perceived as “fanatics”
and form tightly knit “cults” or groups with others who share their paranoid belief systems.
Prevalence
The estimated prevalence of paranoid personality based on a probability subsample from
Part II of the National Comorbidity Survey Replication was 2.3% (Lenzenweger et al.
2007). The prevalence of paranoid personality disorder in the National Epidemiologic
Survey on Alcohol and Related Conditions was 4.4% (Grant et al. 2004). A review of six
epidemiological studies (four in the United States) found a median prevalence of 3.2%
(Morgan and Zimmerman 2018). In forensic settings, the estimated prevalence may be as
high as 23% (Ullrich et al. 2008).
Development and Course
Paranoid personality disorder may be first apparent in childhood and adolescence with
solitariness, poor peer relationships, social anxiety, underachievement in school, and
interpersonal hypersensitivity. Adolescent onset of paranoid personality disorder is
associated with a prior history of childhood maltreatment, externalizing symptoms,
bullying of peers, and adult appearance of interpersonal aggression (Johnson et al. 2000;
Natsuaki et al. 2009).
Risk and Prognostic Factors
Environmental
Exposure to social stressors such as socioeconomic inequality, marginalization, and racism
is associated with decreased trust, which in some cases is adaptive. The combination of
social stress and childhood maltreatment accounts for the increased prevalence of paranoid
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symptoms in social groups facing racial discrimination (Iacovino et al. 2014). Both
longitudinal (Natsuaki et al. 2009) and cross-sectional studies confirm that childhood
trauma is a risk factor for paranoid personality disorder (Lee 2017).
Genetic and physiological
There is some evidence for an increased prevalence of paranoid personality disorder in
relatives of probands with schizophrenia and for a more specific familial relationship with
delusional disorder, persecutory type (Kendler et al. 1985).
Culture-Related Diagnostic Issues
Some behaviors that are influenced by sociocultural contexts or specific life circumstances
may be erroneously labeled paranoid and may even be reinforced by the process of clinical
evaluation. Migrants, members of socially oppressed ethnic and racialized populations, and
other groups facing social adversity, racism, and discrimination may display guarded or
defensive behaviors because of unfamiliarity (e.g., language barriers or lack of knowledge of
rules and regulations) or in response to the neglect, hostility, or indifference of the majority
society (Iacovino et al. 2014; Raza et al. 2014). Some cultural groups develop low
generalized trust, especially of outgroup members, which may lead to behaviors that can be
misjudged as paranoid. These include guardedness, limited outward emotionality,
cognitive rigidity, social distance, and hostility or defensiveness in situations experienced
as unfair or discriminatory (Combs et al. 2002; Mosley et al. 2017; van der Linden 2017;
Van Hoorn 2015; Whaley 2004). These behaviors can, in turn, generate anger and
frustration in others, including clinicians, thus setting up a vicious cycle of mutual mistrust,
which should not be confused with paranoid traits or paranoid personality
disorder (Ahmed et al. 2017; Isbell et al. 2020).
Sex- and Gender-Related Diagnostic Issues
While paranoid personality disorder was found to be more common in men than in women
in a meta-analysis relying on clinical and community samples (Lynam and Widiger 2007),
the National Epidemiologic Survey on Alcohol and Related Conditions found it to be more
common in women (Grant et al. 2004).
Differential Diagnosis
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Other mental disorders with psychotic symptoms
Paranoid personality disorder can be distinguished from delusional disorder, persecutory
type; schizophrenia; and a bipolar or depressive disorder with psychotic features because
these disorders are all characterized by a period of persistent psychotic symptoms (e.g.,
delusions and hallucinations). For an additional diagnosis of paranoid personality disorder
to be given, the personality disorder must have been present before the onset of psychotic
symptoms and must persist when the psychotic symptoms are in remission. When an
individual has another persistent mental disorder (e.g., schizophrenia) that was preceded
by paranoid personality disorder, paranoid personality disorder should also be recorded,
followed by “premorbid” in parentheses.
Personality change due to another medical condition
Paranoid personality disorder must be distinguished from personality change due to
another medical condition, in which the traits that emerge are a direct physiological
consequence of another medical condition.
Substance use disorders
Paranoid personality disorder must be distinguished from symptoms that may develop in
association with persistent substance use.
Paranoid traits associated with physical handicaps
The disorder must also be distinguished from paranoid traits associated with the
development of physical handicaps (e.g., a hearing impairment).
Other personality disorders and personality traits
Other personality disorders may be confused with paranoid personality disorder because
they have certain features in common. It is therefore important to distinguish among these
disorders based on differences in their characteristic features. However, if an individual has
personality features that meet criteria for one or more personality disorders in addition to
paranoid personality disorder, all can be diagnosed. Paranoid personality disorder and
schizotypal personality disorder share the traits of suspiciousness, interpersonal aloofness,
and paranoid ideation, but schizotypal personality disorder also includes symptoms such as
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magical thinking, unusual perceptual experiences, and odd thinking and speech.
Individuals with behaviors that meet criteria for schizoid personality disorder are often
perceived as strange, eccentric, cold, and aloof, but they do not usually have prominent
paranoid ideation. The tendency of individuals with paranoid personality disorder to react
to minor stimuli with anger is also seen in borderline and histrionic personality disorders.
However, these disorders are not necessarily associated with pervasive suspiciousness, and
borderline personality disorder exhibits higher levels of impulsivity and self-destructive
behavior. People with avoidant personality disorder may also be reluctant to confide in
others, but more from fear of being embarrassed or found inadequate than from fear of
others’ malicious intent. Although antisocial behavior may be present in some individuals
with paranoid personality disorder, it is not usually motivated by a desire for personal gain
or to exploit others as in antisocial personality disorder, but rather is more often
attributable to a desire for revenge. Individuals with narcissistic personality disorder may
occasionally display suspiciousness, social withdrawal, or alienation, but this derives
primarily from fears of having their imperfections or flaws revealed.
Paranoid traits may be adaptive, particularly in threatening environments. Paranoid
personality disorder should be diagnosed only when these traits are inflexible, maladaptive,
and persisting and cause significant functional impairment or subjective distress.
Comorbidity
Particularly in response to stress, individuals with this disorder may experience very brief
psychotic episodes (lasting minutes to hours). In some instances, paranoid personality
disorder may appear as the premorbid antecedent of delusional disorder or schizophrenia.
Individuals with paranoid personality disorder may develop major depressive disorder and
may be at increased risk for agoraphobia and obsessive-compulsive disorder. Alcohol and
other substance use disorders frequently occur. The most common co-occurring
personality disorders appear to be schizotypal, schizoid, narcissistic, avoidant, and
borderline.
References: Paranoid Personality Disorder
Ahmed S, Lee S, Shommu N, et al: Experiences of communication barriers between
physicians and immigrant patients: a systematic review and thematic synthesis. Patient
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Experience Journal 4:122–140, 2017
Combs DR, Penn DL, Fenigstein A: Ethnic differences in subclinical paranoia: an
expansion of norms of the Paranoia Scale. Cultur Divers Ethnic Minor Psychol 8(3):248–
256, 2002
Grant BF, Hasin DS, Stinson FS, et al: Prevalence, correlates, and disability of personality
disorders in the United States: results from the National Epidemiologic Survey on Alcohol
and Related Conditions. J Clin Psychiatry 65(7):948–958, 2004
Iacovino JM, Jackson JJ, Oltmanns TF: The relative impact of socioeconomic status and
childhood trauma on black-white differences in paranoid personality disorder symptoms.
J Abnorm Psychol 123(1):225–230, 2014
Isbell LM, Tager J, Beals K, Liu G: Emotionally evocative patients in the emergency
department: a mixed methods investigation of providers’ reported emotions and
implications for patient safety. BMJ Qual Saf 29(10):1–2, 2020
Johnson JP, Cohen E, Smailes S, et al: Adolescent personality disorders associated with
violence and criminal behavior during adolescence and early adulthood. Am J Psychiatry
157(9):1406–1412, 2000
Kendler KS, Masterson CC, Davis KL: Psychiatric illness in first-degree relatives of
patients with paranoid psychosis, schizophrenia and medical illness. Br J Psychiatry
147:524–531, 1985
Lee R: Mistrustful and misunderstood: a review of paranoid personality disorder. Curr
Behav Neurosci Rep 4:151–165, 2017
Lenzenweger MF, Lane MC, Loranger AW, Kessler RC: DSM-IV personality disorders in
the National Comorbidity Survey Replication. Biol Psychiatry 62(6):553–564, 2007
Lynam DR, Widiger TA: Using a general model of personality to understand sex
differences in the personality disorders. J Pers Disord 21(6):583–602, 2007 18072861
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(F60.1)
Morgan TA, Zimmerman M: Epidemiology of personality disorders, in Handbook of
Personality Disorders: Theory, Research, and Treatment, 2nd Edition. Edited by Livesley
WJ, Larstone R. New York, Guilford, 2018, pp 173–196
Mosley DV, Owen KH, Rostosky SS, Reese RJ: Contextualizing behaviors associated with
paranoia: perspectives of black men. Psychology of Men & Masculinity 18(2):165–175,
2017
Natsuaki MN, Cicchetti D, Rogosch FA: Examining the developmental history of child
maltreatment, peer relations, and externalizing problems among adolescents with
symptoms of paranoid personality disorder. Dev Psychopathol 21(4):1181–1193, 2009
Raza GT, DeMarce JM, Lash SJ, Parker JD: Paranoid personality disorder in the United
States: the role of race, illicit drug use, and income. J Ethn Subst Abuse 13(3):247–257,
2014
Ullrich S, Deasy D, Smith J, et al: Detecting personality disorders in the prison population
of England and Wales: comparing case identification using the SCID-II Screen and the
SCID-II Clinical Interview. Journal of Forensic Psychiatry & Psychology 19(3):301–322,
2008
van der Linden M, Hooghe M, de Vroome T, Van Laar C: Extending trust to immigrants:
generalized trust, cross-group friendship and anti-immigrant sentiments in 21 European
societies. PLoS One 12(5):e0177369, 2017
Van Hoorn A: Individualist–collectivist culture and trust radius: a multilevel approach.
Journal of Cross-Cultural Psychology 46(2):269–276, 2015
Whaley AL: Ethnicity/race, paranoia, and hospitalization for mental health problems
among men. Am J Public Health 94(1):78–81, 2004
Schizoid Personality Disorder
Diagnostic Criteria
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A. A pervasive pattern of detachment from social relationships and a restricted
range of expression of emotions in interpersonal settings, beginning by early
adulthood and present in a variety of contexts, as indicated by four (or more) of
the following:
1. Neither desires nor enjoys close relationships, including being part of a
family.
2. Almost always chooses solitary activities.
3. Has little, if any, interest in having sexual experiences with another person.
4. Takes pleasure in few, if any, activities.
5. Lacks close friends or confidants other than first-degree relatives.
6. Appears indifferent to the praise or criticism of others.
7. Shows emotional coldness, detachment, or flattened affectivity.
B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder
or depressive disorder with psychotic features, another psychotic disorder, or
autism spectrum disorder and is not attributable to the physiological effects of
another medical condition.
Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,”
i.e., “schizoid personality disorder (premorbid).”
Diagnostic Features
The essential feature of schizoid personality disorder is a pervasive pattern of detachment
from social relationships and a restricted range of expression of emotions in interpersonal
settings. This pattern begins by early adulthood and is present in a variety of contexts.
Individuals with schizoid personality disorder appear to lack a desire for intimacy, seem
indifferent to opportunities to develop close relationships, and do not seem to derive much
satisfaction from being part of a family or other social group (Criterion A1). They prefer
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spending time by themselves, rather than being with other people. They often appear to be
socially isolated or “loners” and almost always choose solitary activities or hobbies that do
not include interaction with others (Criterion A2). They prefer mechanical or abstract
tasks, such as computer or mathematical games. They may have very little interest in
having sexual experiences with another person (Criterion A3) and take pleasure in few, if
any, activities (Criterion A4). There is usually a reduced experience of pleasure from
sensory, bodily, or interpersonal experiences, such as walking on a beach at sunset or
having sex. These individuals have no close friends or confidants, except possibly a first-
degree relative (Criterion A5).
Individuals with schizoid personality disorder often seem indifferent to the approval or
criticism of others and do not appear to be bothered by what others may think of them
(Criterion A6). They may be oblivious to the normal subtleties of social interaction and
often do not respond appropriately to social cues so that they seem socially inept or
superficial and self-absorbed. They usually display a “bland” exterior without visible
emotional reactivity and rarely reciprocate gestures or facial expressions, such as smiles or
nods (Criterion A7). They claim that they rarely experience strong emotions such as anger
and joy. They often display a constricted affect and appear cold and aloof. However, in
those very unusual circumstances in which these individuals become at least temporarily
comfortable in revealing themselves, they may acknowledge having painful feelings,
particularly related to social interactions.
Schizoid personality disorder should not be diagnosed if the pattern of behavior occurs
exclusively during the course of schizophrenia, a bipolar or depressive disorder with
psychotic features, another psychotic disorder, or autism spectrum disorder, or if it is
attributable to the physiological effects of a neurological (e.g., temporal lobe epilepsy) or
another medical condition (Criterion B).
Associated Features
Individuals with schizoid personality disorder may have particular difficulty expressing
anger, even in response to direct provocation, which contributes to the impression that
they lack emotion. Their lives sometimes seem directionless, and they may appear to “drift”
in their goals. Such individuals often react passively to adverse circumstances and have
difficulty responding appropriately to important life events. Because of their lack of social
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skills and lack of desire for sexual experiences, individuals with this disorder have few
friendships, date infrequently, and often do not marry. Occupational functioning may be
impaired, particularly if interpersonal involvement is required, but individuals with this
disorder may do well when they work under conditions of social isolation.
Prevalence
Schizoid personality disorder is uncommon in clinical settings. The estimated prevalence of
schizoid personality disorder based on a probability subsample from Part II of the National
Comorbidity Survey Replication was 4.9% (Lenzenweger et al. 2007). The prevalence of
schizoid personality disorder in the National Epidemiologic Survey on Alcohol and Related
Conditions was 3.1% (Grant et al. 2004). A review of six epidemiological studies (four in
the United States) found a median prevalence of 1.3% (Morgan and Zimmerman 2018).
Development and Course
Schizoid personality disorder may be first apparent in childhood and adolescence with
solitariness, poor peer relationships, and underachievement in school, which mark these
children or adolescents as different and make them subject to teasing.
Risk and Prognostic Factors
Genetic and physiological
Schizoid personality disorder may have increased prevalence in the relatives of individuals
with schizophrenia or schizotypal personality disorder.
Culture-Related Diagnostic Issues
Individuals from a variety of cultural backgrounds sometimes exhibit defensive behaviors
and interpersonal styles that may be erroneously labeled as “schizoid.” For example, those
who have moved from rural to metropolitan environments may react with “emotional
freezing” that may last for several months and manifest as solitary activities, constricted
affect, and other deficits in communication. Immigrants from other countries are
sometimes mistakenly perceived as cold, hostile, or indifferent, which may be a response to
social ostracism from the host society.
Sex- and Gender-Related Diagnostic Issues
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While some research suggests that schizoid personality disorder may be more common in
men (Furnham and Trickey 2011), other research suggests that there is no gender
difference in prevalence (Grant et al. 2004; Lenzenweger et al. 2007).
Differential Diagnosis
Other mental disorders with psychotic symptoms
Schizoid personality disorder can be distinguished from delusional disorder, schizophrenia,
and a bipolar or depressive disorder with psychotic features because these disorders are all
characterized by a period of persistent psychotic symptoms (e.g., delusions and
hallucinations). To give an additional diagnosis of schizoid personality disorder, the
personality disorder must have been present before the onset of psychotic symptoms and
must persist when the psychotic symptoms are in remission. When an individual has a
persistent psychotic disorder (e.g., schizophrenia) that was preceded by schizoid
personality disorder, schizoid personality disorder should also be recorded, followed by
“premorbid” in parentheses.
Autism spectrum disorder
There may be great difficulty differentiating individuals with schizoid personality disorder
from individuals with autism spectrum disorder, particularly with milder forms of either
disorder, as both include a seeming indifference to companionship with others (Gadow
2013; Hopwood and Thomas 2012). However, autism spectrum disorder may be
differentiated by stereotyped behaviors and interests.
Personality change due to another medical condition
Schizoid personality disorder must be distinguished from personality change due to
another medical condition, in which the traits that emerge are a direct physiological
consequence of another medical condition.
Substance use disorders
Schizoid personality disorder must also be distinguished from symptoms that may develop
in association with persistent substance use.
Other personality disorders and personality traits
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Other personality disorders may be confused with schizoid personality disorder because
they have certain features in common. It is, therefore, important to distinguish among
these disorders based on differences in their characteristic features. However, if an
individual has personality features that meet criteria for one or more personality disorders
in addition to schizoid personality disorder, all can be diagnosed. Although characteristics
of social isolation and restricted affectivity are common to schizoid, schizotypal, and
paranoid personality disorders, schizoid personality disorder can be distinguished from
schizotypal personality disorder by the lack of cognitive and perceptual distortions and
from paranoid personality disorder by the lack of suspiciousness and paranoid ideation.
The social isolation of schizoid personality disorder can be distinguished from that of
avoidant personality disorder, which is attributable to fear of being embarrassed or found
inadequate and excessive anticipation of rejection. In contrast, people with schizoid
personality disorder have a more pervasive detachment and limited desire for social
intimacy. Individuals with obsessive-compulsive personality disorder may also show an
apparent social detachment stemming from devotion to work and discomfort with
emotions, but they do have an underlying capacity for intimacy.
Individuals who are “loners” or quite introverted may display personality traits that might
be considered schizoid, consistent with the broader conceptualization of schizoid
personality disorder as a disorder defined by pathological
introversion/detachment (Samuel and Widiger 2008). Only when these traits are inflexible
and maladaptive and cause significant functional impairment or subjective distress do they
constitute schizoid personality disorder.
Comorbidity
Particularly in response to stress, individuals with this disorder may experience very brief
psychotic episodes (lasting minutes to hours). In some instances, schizoid personality
disorder may appear as the premorbid antecedent of delusional disorder or schizophrenia.
Individuals with this disorder may sometimes develop major depressive disorder. Schizoid
personality disorder most often co-occurs with schizotypal, paranoid, and avoidant
personality disorders.
References: Schizoid Personality Disorder
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(F21)
Furnham A, Trickey G: Sex differences in the dark side traits. Personality and Individual
Differences 50(4):517–522, 2011
Gadow KD: Association of schizophrenia spectrum disorder and autism spectrum
disorder (ASD) symptoms in children with ASD and clinical controls. Res Dev Disabil
34(4):1289–1299, 2013
Grant BF, Hasin DS, Stinson FS, et al: Prevalence, correlates, and disability of personality
disorders in the United States: results from the National Epidemiologic Survey on Alcohol
and Related Conditions. J Clin Psychiatry 65(7):948–958, 2004
Hopwood CJ, Thomas KM: Paranoid and schizoid personality disorders, in The Oxford
Handbook of Personality Disorders. Edited by Widiger TA. New York, Oxford University
Press, 2012, pp 582–602
Lenzenweger MF, Lane MC, Loranger AW, Kessler RC: DSM-IV personality disorders in
the National Comorbidity Survey Replication. Biol Psychiatry 62(6):553–564, 2007
Morgan TA, Zimmerman M: Epidemiology of personality disorders, in Handbook of
Personality Disorders: Theory, Research, and Treatment, 2nd Edition. Edited by Livesley
WJ, Larstone R. New York, Guilford, 2018, pp 173–196
Samuel DB, Widiger TA: A meta-analytic review of the relationships between the five-
factor model and DSM-IV-TR personality disorders: a facet level analysis. Clin Psychol
Rev 28(8):1326–1342, 2008
Schizotypal Personality Disorder
Diagnostic Criteria
A. A pervasive pattern of social and interpersonal deficits marked by acute
discomfort with, and reduced capacity for, close relationships as well as by
cognitive or perceptual distortions and eccentricities of behavior, beginning by
early adulthood and present in a variety of contexts, as indicated by five (or more)
of the following:
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1. Ideas of reference (excluding delusions of reference).
2. Odd beliefs or magical thinking that influences behavior and is inconsistent
with subcultural norms (e.g., superstitiousness, belief in clairvoyance,
telepathy, or “sixth sense”; in children and adolescents, bizarre fantasies or
preoccupations).
3. Unusual perceptual experiences, including bodily illusions.
4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical,
overelaborate, or stereotyped).
5. Suspiciousness or paranoid ideation.
6. Inappropriate or constricted affect.
7. Behavior or appearance that is odd, eccentric, or peculiar.
8. Lack of close friends or confidants other than first-degree relatives.
9. Excessive social anxiety that does not diminish with familiarity and tends to
be associated with paranoid fears rather than negative judgments about self.
B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder
or depressive disorder with psychotic features, another psychotic disorder, or
autism spectrum disorder.
Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,” e.g.,
“schizotypal personality disorder (premorbid).”
Diagnostic Features
The essential feature of schizotypal personality disorder is a pervasive pattern of social and
interpersonal deficits marked by acute discomfort with, and reduced capacity for, close
relationships as well as by cognitive or perceptual distortions and eccentricities of behavior.
This pattern begins by early adulthood and is present in a variety of contexts.
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Individuals with schizotypal personality disorder often have ideas of reference (i.e.,
incorrect interpretations of casual incidents and external events as having a particular and
unusual meaning specifically for the person) (Criterion A1). These should be distinguished
from delusions of reference, in which the beliefs are held with delusional conviction. These
individuals may be superstitious or preoccupied with paranormal phenomena that are
outside the norms of their subculture (Criterion A2). They may feel that they have special
powers to sense events before they happen or to read others’ thoughts. They may believe
that they have magical control over others, which can be implemented directly (e.g.,
believing that their spouse’s taking the dog out for a walk is the direct result of thinking an
hour earlier it should be done) or indirectly through compliance with magical rituals (e.g.,
walking past a specific object three times to avoid a certain harmful outcome). Perceptual
alterations may be present (e.g., sensing that another person is present or hearing a voice
murmuring their name) (Criterion A3). Their speech may include unusual or idiosyncratic
phrasing and construction. It is often loose, digressive, or vague, but without actual
derailment or incoherence (Criterion A4). Responses can be either overly concrete or overly
abstract, and words or concepts are sometimes applied in unusual ways (e.g., the individual
may state that he or she was not “talkable” at work).
Individuals with this disorder are often suspicious and may have paranoid ideation (e.g.,
believing their colleagues at work are intent on undermining their reputation with the boss)
(Criterion A5). They are usually not able to negotiate the full range of affects and
interpersonal cuing required for successful relationships and thus often appear to interact
with others in an inappropriate, stiff, or constricted fashion (Criterion A6). These
individuals are often considered to be odd or eccentric because of unusual mannerisms, an
often unkempt manner of dress that does not quite “fit together,” and inattention to the
usual social conventions (e.g., the individual may avoid eye contact, wear clothes that are
ink stained and ill-fitting, and be unable to join in the give-and-take banter of co-workers)
(Criterion A7).
Individuals with schizotypal personality disorder experience interpersonal relatedness as
problematic and are uncomfortable relating to other people. Although they may express
unhappiness about their lack of relationships, their behavior suggests a decreased desire
for intimate contacts. As a result, they usually have no or few close friends or confidants
other than a first-degree relative (Criterion A8). They are anxious in social situations,
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particularly those involving unfamiliar people (Criterion A9). They will interact with other
individuals when they have to but prefer to keep to themselves because they feel that they
are different and just do not “fit in.” Their social anxiety does not easily abate, even when
they spend more time in the setting or become more familiar with the other people,
because their anxiety tends to be associated with suspiciousness regarding others’
motivations. For example, when attending a dinner party, the individual with schizotypal
personality disorder will not become more relaxed as time goes on, but rather may become
increasingly tense and suspicious.
Schizotypal personality disorder should not be diagnosed if the pattern of behavior occurs
exclusively during the course of schizophrenia, a bipolar or depressive disorder with
psychotic features, another psychotic disorder, or autism spectrum disorder (Criterion B).
Associated Features
Individuals with schizotypal personality disorder often seek treatment for the associated
symptoms of anxiety or depression rather than for the personality disorder features per se.
Prevalence
The estimated prevalence of schizotypal personality disorder based on a probability
subsample from Part II of the National Comorbidity Survey Replication was 3.3%
(Lenzenweger et al. 2007).The prevalence of schizotypal personality disorder in the
National Epidemiologic Survey on Alcohol and Related Conditions data was 3.9% (Pulay et
al. 2009). A review of five epidemiological studies (three in the United States) found a
median prevalence of 0.6% (Morgan and Zimmerman 2018).
Development and Course
Schizotypal personality disorder has a relatively stable course, with only a small proportion
of individuals going on to develop schizophrenia or another psychotic disorder. Schizotypal
personality disorder may be first apparent in childhood and adolescence with solitariness,
poor peer relationships, social anxiety, underachievement in school, hypersensitivity,
peculiar thoughts and language, and bizarre fantasies. These children may appear “odd” or
“eccentric” and attract teasing.
Risk and Prognostic Factors
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Genetic and physiological
Schizotypal personality disorder appears to aggregate familially and is more prevalent
among the first-degree biological relatives of individuals with schizophrenia than among
the general population. There may also be a modest increase in schizophrenia and other
psychotic disorders in the relatives of probands with schizotypal personality disorder. Twin
studies indicate highly stable genetic factors and rather transient environmental factors for
an increased risk for the schizotypal syndrome (Kendler et al. 2015), and genetic risk
variants for schizophrenia may be linked to schizotypal personality disorder (e.g.,
Hodgkinson et al. 2004; Nyegaard et al. 2010). Neuroimaging studies detect group-level
differences in the size and function of specific brain regions in individuals with schizotypal
personality disorder in comparison with healthy persons, individuals with schizophrenia,
and individuals with other personality disorders (e.g., Fervaha and Remington 2013; Rosell
et al. 2014).
Culture-Related Diagnostic Issues
Cognitive and perceptual distortions must be evaluated in the context of the individual’s
cultural milieu. Pervasive culturally determined characteristics, particularly those
regarding supernatural and religious beliefs and practices (life beyond death, speaking in
tongues, voodoo, shamanism, mind reading, sixth sense, evil eye, magical beliefs related to
health and illness), can appear to be schizotypal to the uninformed clinician. Thus,
observed cross-national and cross-ethnic variations in the prevalence and expression of
schizotypal traits may be a true epidemiological finding or one due to differences in the
cultural acceptance of these experiences (Fonseca-Pedrero et al. 2018; Pulay et al. 2009).
Sex- and Gender-Related Diagnostic Issues
Schizotypal personality disorder appears to be slightly more common in men than in
women (Furnham and Trickey 2011; Pulay et al. 2009).
Differential Diagnosis
Other mental disorders with psychotic symptoms
Schizotypal personality disorder can be distinguished from delusional disorder,
schizophrenia, and a bipolar or depressive disorder with psychotic features because these
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disorders are all characterized by a period of persistent psychotic symptoms (e.g., delusions
and hallucinations). To give an additional diagnosis of schizotypal personality disorder, the
personality disorder must have been present before the onset of psychotic symptoms and
persist when the psychotic symptoms are in remission. When an individual has a persistent
psychotic disorder (e.g., schizophrenia) that was preceded by schizotypal personality
disorder, schizotypal personality disorder should also be recorded, followed by
“premorbid” in parentheses.
Neurodevelopmental disorders
There may be great difficulty differentiating children with schizotypal personality disorder
from the heterogeneous group of solitary, odd children whose behavior is characterized by
marked social isolation, eccentricity, or peculiarities of language and whose diagnoses
would probably include milder forms of autism spectrum disorder or language
communication disorders. Communication disorders may be differentiated by the primacy
and severity of the disorder in language and by the characteristic features of impaired
language found in a specialized language assessment. Milder forms of autism spectrum
disorder are differentiated by the even greater lack of social awareness and emotional
reciprocity and stereotyped behaviors and interests.
Personality change due to another medical condition
Schizotypal personality disorder must be distinguished from personality change due to
another medical condition, in which the traits that emerge are a direct physiological
consequence of another medical condition.
Substance use disorders
Schizotypal personality disorder must also be distinguished from symptoms that may
develop in association with persistent substance use.
Other personality disorders and personality traits
Other personality disorders may be confused with schizotypal personality disorder because
they have certain features in common. It is, therefore, important to distinguish among
these disorders based on differences in their characteristic features. However, if an
individual has personality features that meet criteria for one or more personality disorders
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in addition to schizotypal personality disorder, all can be diagnosed. Although paranoid
and schizoid personality disorders may also be characterized by social detachment and
restricted affect, schizotypal personality disorder can be distinguished from these two
diagnoses by the presence of cognitive or perceptual distortions and marked eccentricity or
oddness. Close relationships are limited in both schizotypal personality disorder and
avoidant personality disorder; however, in avoidant personality disorder an active desire
for relationships is constrained by a fear of rejection, whereas in schizotypal personality
disorder there is a lack of desire for relationships and persistent detachment. Individuals
with narcissistic personality disorder may also display suspiciousness, social withdrawal, or
alienation, but in narcissistic personality disorder these qualities derive primarily from
fears of having imperfections or flaws revealed. Individuals with borderline personality
disorder may also have transient, psychotic-like symptoms, but these are usually more
closely related to affective shifts in response to stress (e.g., intense anger, anxiety,
disappointment) and are usually more dissociative (e.g., derealization, depersonalization).
In contrast, individuals with schizotypal personality disorder are more likely to have
enduring psychotic-like symptoms that may worsen under stress but are less likely to be
invariably associated with pronounced affective symptoms. Although social isolation may
occur in borderline personality disorder, it is usually secondary to repeated interpersonal
failures due to angry outbursts and frequent mood shifts, rather than a result of a
persistent lack of social contacts and desire for intimacy. Furthermore, individuals with
schizotypal personality disorder do not usually demonstrate the impulsive or manipulative
behaviors of the individual with borderline personality disorder. However, there is a high
rate of co-occurrence between the two disorders, so that making such distinctions is not
always feasible. Schizotypal features during adolescence may be reflective of transient
emotional turmoil rather than an enduring personality disorder.
Comorbidity
Particularly in response to stress, individuals with this disorder may experience transient
psychotic episodes (lasting minutes to hours), although they usually are insufficient in
duration to warrant an additional diagnosis such as brief psychotic disorder or
schizophreniform disorder. In some cases, clinically significant psychotic symptoms may
develop that meet criteria for brief psychotic disorder, schizophreniform disorder,
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delusional disorder, or schizophrenia. There is considerable co-occurrence with schizoid,
paranoid, avoidant, and borderline personality disorders.
References: Schizotypal Personality Disorder
Fervaha G, Remington G: Neuroimaging findings in schizotypal personality disorder: a
systematic review. Prog Neuropsychopharmacol Biol Psychiatry 43:96–107, 2013
Fonseca-Pedrero E, Chan RCK, Debbané M, et al: Comparisons of schizotypal traits across
12 countries: results from the International Consortium for Schizotypy Research.
Schizophr Res 199:128–134, 2018
Furnham A, Trickey G: Sex differences in the dark side traits. Personality and Individual
Differences 50(4):517–522, 2011
Hodgkinson CA, Goldman D, Jaeger J, et al: Disrupted in schizophrenia 1 (DISC1):
association with schizophrenia, schizoaffective disorder, and bipolar disorder. Am J Hum
Genet 75(5):862–872, 2004
Kendler KS, Aggen SH, Neale MC, et al: A longitudinal twin study of cluster A personality
disorders. Psychol Med 45(7):1531–1538, 2015
Lenzenweger MF, Lane MC, Loranger AW, Kessler RC: DSM-IV personality disorders in
the National Comorbidity Survey Replication. Biol Psychiatry 62(6):553–564, 2007
Morgan TA, Zimmerman M: Epidemiology of personality disorders, in Handbook of
Personality Disorders: Theory, Research, and Treatment, 2nd Edition. Edited by Livesley
WJ, Larstone R. New York, Guilford, 2018, pp 173–196
Nyegaard M, Demontis D, Foldager L, et al: CACNA1C (rs1006737) is associated with
schizophrenia. Mol Psychiatry 15(2):119–121, 2010
Pulay AJ, Stinson FS, Dawson DA, et al: Prevalence, correlates, disability, and
comorbidity of DSM-IV schizotypal personality disorder: results from the wave 2 national
epidemiologic survey on alcohol and related conditions. Prim Care Companion J Clin
Psychiatry 11(2):53–67, 2009
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(F60.2)
Rosell DR, Futterman SE, McMaster A, Siever LJ: Schizotypal personality disorder: a
current review. Curr Psychiatry Rep 16(7):452, 2014
Cluster B Personality Disorders
Antisocial Personality Disorder
Diagnostic Criteria
A. A pervasive pattern of disregard for and violation of the rights of others, occurring
since age 15 years, as indicated by three (or more) of the following:
1. Failure to conform to social norms with respect to lawful behaviors, as
indicated by repeatedly performing acts that are grounds for arrest.
2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning
others for personal profit or pleasure.
3. Impulsivity or failure to plan ahead.
4. Irritability and aggressiveness, as indicated by repeated physical fights or
assaults.
5. Reckless disregard for safety of self or others.
6. Consistent irresponsibility, as indicated by repeated failure to sustain
consistent work behavior or honor financial obligations.
7. Lack of remorse, as indicated by being indifferent to or rationalizing having
hurt, mistreated, or stolen from another.
B. The individual is at least age 18 years.
C. There is evidence of conduct disorder with onset before age 15 years.
D. The occurrence of antisocial behavior is not exclusively during the course of
schizophrenia or bipolar disorder.
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Diagnostic Features
The essential feature of antisocial personality disorder is a pervasive pattern of disregard
for, and violation of, the rights of others that begins in childhood or early adolescence and
continues into adulthood. This pattern has also been referred to as psychopathy,
sociopathy, or dyssocial personality disorder. Because deceit and manipulation are central
features of antisocial personality disorder, it may be especially helpful to integrate
information acquired from systematic clinical assessment with information collected from
collateral sources.
For this diagnosis to be given, the individual must be at least age 18 years (Criterion B) and
must have had evidence of conduct disorder with onset before age 15 years (Criterion C).
Conduct disorder involves a repetitive and persistent pattern of behavior in which the basic
rights of others or major age-appropriate societal norms or rules are violated. The specific
behaviors characteristic of conduct disorder fall into one of four categories: aggression to
people and animals, destruction of property, deceitfulness or theft, or serious violation of
rules.
The pattern of antisocial behavior continues into adulthood. Individuals with antisocial
personality disorder fail to conform to social norms with respect to lawful behavior
(Criterion A1). They may repeatedly perform acts that are grounds for arrest (whether they
are arrested or not), such as destroying property, harassing others, stealing, or pursuing
illegal occupations. Persons with this disorder disregard the wishes, rights, or feelings of
others. They are frequently deceitful and manipulative in order to gain personal profit or
pleasure (e.g., to obtain money, sex, or power) (Criterion A2). They may repeatedly lie, use
an alias, con others, or malinger. A pattern of impulsivity may be manifested by a failure to
plan ahead (Criterion A3). Decisions are made on the spur of the moment, without
forethought and without consideration for the consequences to self or others; this may lead
to sudden changes of jobs, residences, or relationships. Individuals with antisocial
personality disorder tend to be irritable and aggressive and may repeatedly get into
physical fights or commit acts of physical assault (including spouse beating or child
beating) (Criterion A4). (Aggressive acts that are required to defend oneself or someone
else are not considered to be evidence for this item.) These individuals also display a
reckless disregard for the safety of themselves or others (Criterion A5). This may be
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evidenced in their driving behavior (i.e., recurrent speeding, driving while intoxicated,
multiple accidents). They may engage in sexual behavior or substance use that has a high
risk for harmful consequences. They may neglect or fail to care for a child in a way that puts
the child in danger.
Individuals with antisocial personality disorder also tend to be consistently and extremely
irresponsible (Criterion A6). Irresponsible work behavior may be indicated by significant
periods of unemployment despite available job opportunities, or by abandonment of
several jobs without a realistic plan for getting another job. There may also be a pattern of
repeated absences from work that are not explained by illness either in themselves or in
their family. Financial irresponsibility is indicated by acts such as defaulting on debts,
failing to provide child support, or failing to support other dependents on a regular basis.
Individuals with antisocial personality disorder show little remorse for the consequences of
their acts (Criterion A7). They may be indifferent to, or provide a superficial rationalization
for, having hurt, mistreated, or stolen from someone (e.g., “life’s unfair,” “losers deserve to
lose”). These individuals may blame the victims for being foolish, helpless, or deserving
their fate (e.g., “he had it coming anyway”); they may minimize the harmful consequences
of their actions; or they may simply indicate complete indifference. They generally fail to
compensate or make amends for their behavior. They may believe that everyone is out to
“help number one” and that one should stop at nothing to avoid being pushed around.
The antisocial behavior must not occur exclusively during the course of schizophrenia or
bipolar disorder (Criterion D).
Associated Features
Individuals with antisocial personality disorder frequently lack empathy and tend to be
callous, cynical, and contemptuous of the feelings, rights, and sufferings of others. They
may have an inflated and arrogant self-appraisal (e.g., feel that ordinary work is beneath
them or lack a realistic concern about their current problems or their future) and may be
excessively opinionated, self-assured, or cocky. Some antisocial individuals may display a
glib, superficial charm and can be quite voluble and verbally facile (e.g., using technical
terms or jargon that might impress someone who is unfamiliar with the topic). Lack of
empathy, inflated self-appraisal, and superficial charm are features that have been
commonly included in traditional conceptions of psychopathy that may be particularly
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distinguishing of the disorder and more predictive of recidivism in prison or forensic
settings, where criminal, delinquent, or aggressive acts are likely to be nonspecific. These
individuals may also be irresponsible and exploitative in their sexual relationships. They
may have a history of many sexual partners and may never have sustained a monogamous
relationship. They may be irresponsible as parents, as evidenced by malnutrition of a child,
an illness in the child resulting from a lack of minimal hygiene, a child’s dependence on
neighbors or nonresident relatives for food or shelter, a failure to arrange for a caretaker
for a young child when the individual is away from home, or repeated squandering of
money required for household necessities. These individuals may receive dishonorable
discharges from the armed services, may fail to be self-supporting, may become
impoverished or even homeless, or may spend many years in penal institutions. Individuals
with antisocial personality disorder are more likely than individuals in the general
population to die prematurely from natural causes and suicide (Krasnova et al. 2019).
Prevalence
The estimated prevalence of antisocial personality disorder based on a probability
subsample from Part II of the National Comorbidity Survey Replication was 0.6%
(Lenzenweger et al. 2007).The prevalence of antisocial personality disorder in the National
Epidemiologic Survey on Alcohol and Related Conditions data was 3.6% (Grant et al.
2004). A review of seven epidemiological studies (six in the United States) found a median
prevalence of 3.6% (Morgan and Zimmerman 2018). The highest prevalence of antisocial
personality disorder (greater than 70%) is among samples of men with the most severe
alcohol use disorders (Bucholz et al. 2000) and from substance abuse clinics, prisons, or
other forensic settings (Moran et al. 1999). Lifetime prevalence appears to be similar across
non-Latinx White and Black individuals and lower in Latinx and Asian
Americans (Goldstein et al. 2017). Prevalence may be higher in sam ples affected by
adverse socioeconomic (i.e., poverty) or sociocultural (i.e., migration) factors.
Development and Course
Antisocial personality disorder has a chronic course but may become less evident or remit
as the individual grows older, often by age 40 (Black 2015). Although this remission tends
to be particularly evident with respect to engaging in criminal behavior, there is likely to be
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a decrease in the full spectrum of antisocial behaviors and substance use. By definition,
antisocial personality cannot be diagnosed before age 18 years.
Risk and Prognostic Factors
Environmental
Child abuse or neglect, unstable or erratic parenting, or inconsistent parental discipline
may increase the likelihood that conduct disorder will evolve into antisocial personality
disorder.
Genetic and physiological
Antisocial personality disorder is more common among the first-degree biological relatives
of those with the disorder than in the general population. Biological relatives of individuals
with this disorder are also at increased risk for somatization disorder (a diagnosis that was
replaced in DSM-5 with somatic symptom disorder) and substance use disorders. Within a
family that has a member with antisocial personality disorder, males more often have
antisocial personality disorder and substance use disorders, whereas females more often
have somatization disorder (Javdani et al. 2011).
Culture-Related Diagnostic Issues
Antisocial personality disorder has been associated with low socioeconomic status and
urban settings. The diagnosis may at times be misapplied to individuals in settings in which
seemingly antisocial behavior may be part of a protective survival strategy (e.g., formation
of youth gangs in urban areas with high rates of violence and discrimination). Sociocultural
contexts with high rates of child maltreatment or exposure to violence also tend to have
elevated prevalence of antisocial behaviors, suggesting either a potential risk factor for the
development of antisocial personality disorder or an adverse environment that evokes
reactive and contextual antisocial behaviors that do not represent pervasive and enduring
traits consistent with a personality disorder (Jervis et al. 2014; Kounou et al. 2015; Liu et
al. 2012). In assessing antisocial traits, it is helpful for the clinician to consider the social
and economic context in which the behaviors occur. In the National Epidemiologic Survey
on Alcohol and Related Conditions, prevalence appears to vary across U.S. ethnic and
racialized groups, possibly because of a combination of true prevalence differences,
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measurement artifacts, and the impact of adverse environments that generate behaviors
that resemble those of antisocial personality disorder but are instead reactive and
contextual (Goldstein et al. 2017). Individuals from some socially oppressed groups may be
at higher risk for misdiagnosis or overdiagnosis of antisocial personality disorder because
they are more likely to be misdiagnosed with conduct disorder in adolescence (Baglivio et
al. 2017; Caldwell et al. 2016; Fadus et al. 2020; Mandell et al. 2007; Rousseau et al. 2008),
which is a requirement for a diagnosis of antisocial personality disorder.
Sex- and Gender-Related Diagnostic Issues
Antisocial personality disorder is three times as common in men than in women (Compton
et al. 2005). Women with antisocial personality disorder are more likely to have
experienced childhood and adult adverse experiences such as sexual abuse compared with
men (Alegria et al. 2013). Clinical presentation may vary, with men more often presenting
with irritability/aggression and reckless disregard for the safety of others compared with
women (Alegria et al. 2013). Comorbid substance use disorders are more common in men,
while comorbid mood and anxiety disorders are more common in women (Alegria et al.
2013).There has been some concern that antisocial personality disorder may be
underdiagnosed in females, particularly because of the emphasis on aggressive items in the
definition of conduct disorder (Alegria et al. 2013; Paris et al. 2013).
Differential Diagnosis
The diagnosis of antisocial personality disorder is not given to individuals younger than 18
years and is given only if there is evidence of conduct disorder before age 15 years. For
individuals older than 18 years, a diagnosis of conduct disorder is given only if the criteria
for antisocial personality disorder are not met.
Substance use disorders
When antisocial behavior in an adult is associated with a substance use disorder, the
diagnosis of antisocial personality disorder is not made unless the signs of antisocial
personality disorder were also present in childhood and have continued into adulthood.
When substance use and antisocial behavior both began in childhood and continued into
adulthood, both a substance use disorder and antisocial personality disorder should be
diagnosed if the criteria for both are met, even though some antisocial acts may be a
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consequence of the substance use disorder (e.g., illegal selling of drugs, thefts to obtain
money for drugs).
Schizophrenia and bipolar disorders
Antisocial behavior that occurs exclusively during the course of schizophrenia or a bipolar
disorder should not be diagnosed as antisocial personality disorder.
Other personality disorders
Other personality disorders may be confused with antisocial personality disorder because
they have certain features in common. It is therefore important to distinguish among these
disorders based on differences in their characteristic features. However, if an individual has
personality features that meet criteria for one or more personality disorders in addition to
antisocial personality disorder, all can be diagnosed. Individuals with antisocial personality
disorder and narcissistic personality disorder share a tendency to be tough-minded, glib,
superficial, exploitative, and lack empathy. However, narcissistic personality disorder does
not include characteristics of impulsivity, aggression, and deceit. In addition, individuals
with antisocial personality disorder may not be as needy of the admiration and envy of
others, and persons with narcissistic personality disorder usually lack the history of
conduct disorder in childhood or criminal behavior in adulthood. Individuals with
antisocial personality disorder and histrionic personality disorder share a tendency to be
impulsive, superficial, excitement seeking, reckless, seductive, and manipulative, but
persons with histrionic personality disorder tend to be more exaggerated in their emotions
and do not characteristically engage in antisocial behaviors. Individuals with histrionic and
borderline personality disorders are manipulative to gain nurturance, whereas those with
antisocial personality disorder are manipulative to gain profit, power, or some other
material gratification. Individuals with antisocial personality disorder tend to be less
emotionally unstable and more aggressive than those with borderline personality disorder.