Personality Disorders

Paranoid       Schizoid       Schizotypal       Antisocial       Borderline

Histrionic       Narcissistic       Avoidant       Dependent       Obsessive-Compulsive

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Generic Criteria for Personality Disorders

• A lasting pattern of behavior and inner experience that markedly deviates from norms of the patient's culture. The pattern is manifested in at least 2 of these areas:
  -Affect (appropriateness, intensity, lability and range of emotions)
  -Cognition (how the patient perceives and interprets self, others and events)
  -Impulse control
  -Interpersonal functioning

• This pattern is fixed and affects many personal and social situations.

• These symptoms cause clinically important distress or impair work, social or personal functioning.

• This stable pattern has lasted a long time, with roots in adolescence or young adulthood.

• The symptoms aren't better explained by another mental disorder.

• They aren't directly caused by a general medical condition or substance use, including medications and drugs of abuse.

Coding Notes

If the personality disorder is the only diagnosis or the main reason the patient has come for evaluation, "(Principal Diagnosis)" should be appended to the Axis II diagnosis. For example:

Axis I V71.09 No diagnosis

Axis II 301.0 Paranoid Personality Disorder (Principal Diagnosis)

A frequently used defense mechanism can be indicated on the Axis II line:

Axis II 301.0 Paranoid Personality Disorder; Frequent use of projection

If this personality disorder preceded a psychotic disorder (most often, Schizophrenia), the diagnosis might read:

Axis I 295.10 Schizophrenia, Disorganized Type, Continuous, With Prominent Negative Symptoms

Axis II 301.22 Schizoid Personality Disorder (Premorbid)

Paranoid Personality Disorder

• Beginning by early adult life, the patient is distrustful and suspicious of others, whose motives are seen as malevolent. These attitudes are present in a variety of situations and shown by at least 4 of:
  -Unfounded suspicion that other are deceiving, exploiting or harming the patient
  -Preoccupation with unjustified doubts as to the loyalty or trustworthiness of associates or friends
  -Reluctance to confide in others due to unwarranted fears that information will be maliciously used against the patient
  -Interprets hidden, demeaning or threatening content into ordinary events or comments
  -Persistently bears grudges
  -Imagines personal attacks on own reputation or character that others do not perceive; the patient responds quickly with anger or counterattacks
  -Unjustified, recurring suspicions about the fidelity of spouse or sexual partner

• These symptoms do not occur solely in the course of a psychotic disorder (such as Schizophrenia) or Mood Disorder With Psychotic Features.

• They aren't directly caused by a general medical condition.

Coding Note

If the above criteria are fulfilled prior to the onset of Schizophrenia, "Premorbid" should be added as a qualifier.

Schizoid Personality Disorder

• Beginning by early adult life, isolation from social relationships and restricted emotional range in interpersonal settings. These attitudes are present in a variety of situations and shown by at least 4 of:
  -Neither wants nor likes close relationships, including family
  -Nearly always prefers solitary activities
  -Has little interest in sexual activity with another person
  -Enjoys few activities, if any
  -Other than close relatives, has no close friends or confidants
  -Does not appear affected by criticism or praise
  -Is emotionally cold, detached or bland

• These symptoms do not occur solely in the course of another psychotic disorder (such as Schizophrenia), Mood Disorder With Psychotic Features or a Pervasive Developmental Disorder.

• They aren't directly caused by a general medical condition.

Coding Note

If the above criteria are fulfilled prior to the onset of Schizophrenia, "Premorbid" should be added as a qualifier.

Schizotypal Personality Disorder

• Beginning by early adult life, these patients experience isolation and discomfort with social relationships as well as cognitive or perceptual distortions and peculiar behavior. These qualities are present in a variety of situations and shown by at least 5 of:
  -Ideas of reference (not delusional)
  -Behavior is influenced by odd beliefs or magical thinking inconsistent with cultural norms (includes marked superstitions, belief in telepathy)*
  -Unusual perceptions or bodily illusions
  -Odd speech (vague, excessively abstract, impoverished)
  -Paranoid or suspicious ideas
  -Affect that is constricted in range or inappropriate to the topic
  -Odd behavior or appearance
  -Other than close relatives, no close friends or confidants
  -In social situations, marked anxiety that is not reduced by familiarity. This is associated with paranoid fears rather than negative self-judgments.

• This syndrome does not occur only in the course of Schizophrenia or another psychotic disorder, Mood Disorder With Psychotic Features or Pervasive Developmental Disorder.

Coding Notes

If the above criteria are fulfilled before the onset of Schizophrenia, "Premorbid" should be added as a qualifier.

*In children, odd beliefs may be bizarre fantasies or preoccupations.

Antisocial Personality Disorder

• Before age fifteen, for 12 months or more the patient repeatedly violated rules, age-appropriate societal norms or the rights of others (Conduct Disorder). This was shown by at least 3 of:
  Aggression against people or animals
  -Frequent bullying or threatening
  -Often starts fights
  -Used a weapon that could cause serious injury (gun, knife, club, broken glass)
  -Physical cruelty to people
  -Physical cruelty to animals
  -Theft with confrontation (armed robbery, extortion, mugging, purse snatching)
  -Forced sex upon someone
  Property destruction
  -Deliberately set fires to cause serious damage
  -Deliberately destroyed the property of others (except fire-setting)
  Lying or theft
  -Broke into building, car or house belonging to someone else
  Frequently lied or broke promises for gain or to avoid obligations ("conning")
  -Stole valuables without confrontation (burglary, forgery, shoplifting)
  Serious rule violation
  -Beginning by age twelve, frequently stayed out at night against parents' wishes
  -Runaway from parents overnight twice or more (once if for an extended period)
  -Frequent truancy by age twelve

• Since age fifteen, the patient has shown disregard for the rights of others in a variety of situations. This is demonstrated by at least 3 of:
  -Repeated behaviors that are grounds for arrest, whether arrested or not
  -Lies, uses aliases or cons others for gain or gratification
  -Is impulsive or does not plan ahead
  -Irritability and aggression lead to recurrent physical fights or assaults
  -Recklessly disregards safety of self or others
  -Shows irresponsibility by repeated failure to sustain employment or honor financial obligations
  -Lacks remorse for own injurious behavior (shows indifference or rationalizes)

• The patient is currently at least eighteen years old.

• The antisocial behavior does not occur solely during a Manic Episode or Schizophrenia.

Borderline Personality Disorder

• Beginning by early adult life, the patient has unstable impulse control, interpersonal relationships, moods and self-image. These persistent or recurrent qualities are present in a variety of situations and shown by at least 5 of:
  -Frantic attempts to prevent abandonment, whether real or imagined (don't include self-injurious or suicidal behaviors, covered below)
  -Unstable relationships that alternate between idealization and devaluation
  -Identity disturbance (severely distorted or unstable self-image or sense of self)
  -Potentially self-damaging impulsiveness in at least 2 areas such as binge eating, reckless driving, sex, spending, substance abuse (don't include suicidal or self-mutilating behaviors)
  -Self-mutilation or suicide thoughts, threats or other behavior
  -Severe reactivity of mood creates marked instability (mood swings of intense anxiety, depression, irritability last a few hours to a few days)
  -Chronic feelings of boredom or emptiness
  -Anger that is out of control or inappropriate and intense (demonstrated by frequent temper displays, repeated physical fights or feeling constantly angry)
  -Brief paranoid ideas or severe dissociative symptoms related to stress

Histrionic Personality Disorder

• Beginning by early adult life, emotional excess and attention-seeking behaviors are present in a variety of situations and shown by at least 5 of:
  -Discomfort with situations in which the patient is not the center of attention
  -Relationships that are frequently fraught with inappropriately seductive or sexually provocative behavior
  -Expression of emotion is shallow and rapidly shifting
  -Frequent focusing of attention on self through use of physical appearance
  -Speech is vague and lacks detail
  -Overly dramatic expression of emotion
  -Easy suggestibility (patient is readily influenced by opinions of other people or by circumstances)
  -Belief that relationships are more intimate than they really are

Narcissistic Personality Disorder

• Beginning by early adult life, grandiosity (fantasized or actual), lack of empathy and need for admiration are present in a variety of situations and shown by at least 5 of:
  -A grandiose sense of self-importance (patient exaggerates own abilities and accomplishments)
  -Preoccupation with fantasies of beauty, brilliance, ideal love, power or limitless success
  -Belief that personal uniqueness renders the patient fit only for association with (or understanding by) people or institutions of rarefied status
  -Need for excessive admiration
  -A sense of entitlement (patient unreasonably expects favorable treatment or automatic granting of own wishes
  -Exploitation of others to achieve personal goals
  -Lack of empathy (patient does not recognize or identify with the feelings and needs of others)
  -Frequent envy of others or belief that others envy patient
  -Arrogance or haughtiness in attitude or behavior

Avoidant Personality Disorder

• Beginning by early adult life, social inhibition, hypersensitivity to criticism and feelings of inadequacy are present in a variety of situations and shown by at least 4 of:
  -Fears criticism, disapproval or rejection to the extent of avoiding material interpersonal contact in an occupation
  -Will only become involved with others if certain of being liked
  -Is restrained in intimate relationships for fear of ridicule or shame
  -In social situations, is preoccupied with concerns of being criticized or rejected
  -Experiences inhibitions in new relationships, stemming from feelings of inadequacy
  -Is convinced of being inferior, unappealing, or inept
  -For fear of embarrassment, avoids personal risk or new activities

Dependent Personality Disorder

• Beginning by early adult life, a need to be taken care of leads to clinging, submissive behavior and fears of separation that are present in a variety of situations and shown by at least 5 of:
  -Need for excessive advice and reassurance to make everyday decisions
  -Need for others to be responsible for most major life areas
  -Feared loss of approval or support, leading to difficulty with expressing disagreement (don't count fears of retaliation that are realistic)
  -Trouble with starting projects or carrying them out independently (this must be due to low self-confidence, not due to low motivation or energy)
  -To gain nurture and support, willingness to go to excessive lengths (even volunteer for unpleasant tasks)
  -When alone, exaggerated fears of incapacity for self-care, leading to feelings of discomfort or helplessness
  -If one close relationship is lost, urgent seeking of another to provide care and support
  -Preoccupation with unrealistic fears of being abandoned to provide own care

Obsessive-Compulsive Personality Disorder

• Beginning by early adult life, preoccupation with control, orderliness and perfection overshadow qualities of efficiency, flexibility and candor. These behaviors are present in a variety of situations and shown by at least 4 of:
  -Is absorbed with details, lists, order, organization, rules or schedules to such an extent that the purpose of the activity is lost ("can't see the forest for the trees")
  -Perfectionistic to a degree that interferes with completing the task
  -Is a workaholic (works to exclusion of leisure activities)
  -To a degree out of keeping with cultural or religious influence, is overly conscientious, inflexible or scrupulous about ethics, morals or values
  -Saves worthless items of no real or sentimental value
  -Won't cooperate or delegate tasks unless others agree to do things the patient's way
  -Is stingy toward self and others; hoards money against future need
  -Is rigid and stubborn

301.9  Personality Disorder Not Otherwise Specified

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