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Personality disorder, formerly referred to as a Character Disorder, is a class of mental disorders characterized by rigid and on-going patterns of thought and action (Cognitive modules). The underlying belief systems informing these patterns are referred to as fixed fantasies or "dysfunctional schemata". The inflexibility and pervasiveness of these behavioral patterns often cause serious personal and social difficulties, as well as a general functional impairment.

Personality disorders

Personality disorders are defined by the American Psychiatric Association (APA) as "an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the culture of the individual who exhibits it". [1] These patterns, as noted, are inflexible and pervasive across many situations, due in large part to the fact that such behavior is ego-syntonic (i.e., the patterns are consistent with the ego integrity of the individual), and therefore, perceived to be appropriate by that individual. The onset of these patterns of behavior can typically be traced back to late adolescence and the beginning of adulthood, and, in rare instances, childhood.

Personality disorders are also defined by the International Statistical Classification of Diseases and Related Health Problems (ICD-10) which is published by the World Health Organization. Personality disorders are categorized in ICD-10 Chapter V: Mental and behavioural disorders, specifically under Mental and behavioral disorders: 28F60-F69.29 Disorders of adult personality and behavior. It is seeking to develop an international diagnostic system. The ICD-10 has been structured in part to mesh the DSM's multiaxial system and diagnostic formats.

List of Personality disorders by cluster
Definition of Personality
Psychological Testing for Personality Disorders
Paranoid personality disorder
Schizoid personality disorder
Schizotypal personality disorder
Antisocial personality disorder
Borderline personality disorder
Histrionic personality disorder
Narcissistic personality disorder
Avoidant personality disorder
Dependent personality disorder
Obsessive-compulsive personality disorder
Dissocial personality disorder
Emotionally Unstable Personality Disorder
See also

List of personality disorders defined in the DSM

The DSM-IV lists ten personality disorders, grouped into three clusters. The DSM also contains a category for behavioral patterns that do not match these ten disorders, but nevertheless exhibit characteristics of a personality disorder. This category is labeled Personality Disorder NOS.

Cluster A (odd or eccentric disorders)

Paranoid personality disorder: characterized by irrational suspicions and mistrust of others
Schizoid personality disorder: lack of interest in social relationships, seeing no point in sharing time with others
Schizotypal personality disorder: also avoids social relationships, though out of a fear of people

Cluster B (dramatic, emotional, or erratic disorders)

Antisocial personality disorder: "pervasive disregard for the law and the rights of others."
Borderline personality disorder: extreme "black and white" thinking, instability in relationships, self-image, identity and behavior
Histrionic personality disorder: "pervasive attention-seeking behavior including inappropriate sexual seductiveness and shallow or exaggerated emotions
Narcissistic personality disorder: "a pervasive pattern of grandiosity, need for admiration, and a lack of empathy"

Cluster C (anxious or fearful disorders)

Avoidant personality disorder: social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation and avoidance of social interaction
Dependent personality disorder: pervasive psychological dependence on other people.
Obsessive-compulsive personality disorder (not the same as Obsessive-compulsive disorder): characterized by rigid conformity to rules, moral codes, and excessive orderliness

Definition of Personality

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision [Washington DC, American Psychiatric Association, 2000] defines "personality" as:

"…enduring patterns of perceiving, relating to, and thinking about the environment and oneself … exhibited in a wide range of important social and personal contexts."

Characteristics common to all personality disorders
Patients with personality disorders share certain characteristics:

1. Except those suffering from the Schizoid or the Avoidant Personality Disorders, they are insistent and demand preferential and privileged treatment. They complain about numerous symptoms, though they frequently second guess the diagnosis and disobey the physician, his treatment recommendations and instructions.

2. They feel unique, are affected with grandiosity and a diminished capacity for empathy. Consequently, they regard the physician as inferior to them, alienate him and bore him with their self-preoccupation.

3. They are manipulative and exploitative, trust no one and find it difficult to love or share. They are socially maladaptive and emotionally labile.

4. Disturbed cognitive and, mainly, emotional development peaks in adolescence.

5. Personality disorders are stable and all-pervasive – not episodic or transient. They affect all the dimensions of the patient's life: his career, his interpersonal relationships, his social functioning.

6. Though the patient is sometimes depressed and suffers from mood and anxiety disorders - defenses - splitting, projection, projective identification, denial, intellectualization - are so strong, that the patient is unaware of the reasons for his distress. The character problems, behavioral deficits and emotional deficiencies and instability encountered by the patient with personality disorder are, mostly, ego-syntonic. This means that the patient does not, on the whole, find his personality traits or behavior objectionable, unacceptable, disagreeable, or alien to his self.

7. The patient is prone to suffer from other psychiatric disturbances, both personality disorders and Axis I disorders ("co-morbidity"). Substance abuse and reckless behaviors are also common ("dual diagnosis").

8. Defenses are alloplastic: patients tend to blame the external world for their misfortune and failures. In stressful situations, they try to preempt a (real or imaginary) threat, change the rules of the game, introduce new variables, or otherwise influence the external world to conform to their needs.

9. The personality-disordered are not psychotic. They have no hallucinations, delusions or thought disorders (except those who suffer from a Borderline Personality Disorder and who experience brief psychotic "microepisodes", mostly during treatment). They are also fully oriented, with clear senses (sensorium), good memory and general fund of knowledge.
Differential Diagnoses
The classification of Axis II personality disorders - deeply ingrained, maladaptive, lifelong behavior patterns - in the Diagnostic and Statistical Manual, fourth edition, text revision [American Psychiatric Association. DSM-IV-TR, Washington, 2000] - or the DSM-IV-TR for short - has come under sustained and serious criticism from its inception in 1952.

The DSM IV-TR adopts a categorical approach, postulating that personality disorders are "qualitatively distinct clinical syndromes" (p. 689). This is widely doubted. Even the distinction made between "normal" and "disordered" personalities is increasingly being rejected. The "diagnostic thresholds" between normal and abnormal are either absent or weakly supported.

The polythetic form of the DSM's Diagnostic Criteria - only a subset of the criteria is adequate grounds for a diagnosis - generates unacceptable diagnostic heterogeneity. In other words, people diagnosed with the same personality disorder may share only one criterion or none.

The DSM fails to clarify the exact relationship between Axis II and Axis I disorders and the way chronic childhood and developmental problems interact with personality disorders;

The differential diagnoses are vague and the personality disorders are insufficiently demarcated. The result is excessive co-morbidity (multiple Axis II diagnoses);

The DSM contains little discussion of what distinguishes normal character (personality), personality traits, or personality style (Millon) - from personality disorders;

A dearth of documented clinical experience regarding both the disorders themselves and the utility of various treatment modalities;

Numerous personality disorders are "not otherwise specified" - a catchall, basket "category";

Cultural bias is evident in certain disorders (such as the Antisocial and the Schizotypal);

The emergence of dimensional alternatives to the categorical approach is acknowledged in the DSM-IV-TR itself:

“An alternative to the categorical approach is the dimensional perspective that Personality Disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another” (p.689)

The following issues - long neglected in the DSM - are likely to be tackled in future editions as well as in current research:

The longitudinal course of the disorder(s) and their temporal stability from early childhood onwards

The genetic and biological underpinnings of personality disorder(s)

The development of personality psychopathology during childhood and its emergence in adolescence

The interactions between physical health and disease and personality disorders

The effectiveness of various treatments - talk therapies as well as psychopharmacology.

Psychological Testing for Personality Disorders

A qualified mental health diagnostician administers lengthy tests and personal interviews to determine the existence and virulence of a personality disorder.

The predictive power of these tests - often based on literature and scales of traits constructed by scholars - is hotly disputed. Still, they are far preferable to subjective impressions of the diagnostician which are often amenable to manipulation.

The Minnesota Multiphasic Personality Inventory. Diagnostic test composed of 567 true-or-false questions arranged in three validity scales and ten dimensional clinical scales. The latter

measure hypochondriasis, depression, hysteria, psychopathic deviation, masculinity-femininity, paranoia, psychasthenia, schizophrenia, hypomania, and social introversion. There are also scales for alcoholism, post-traumatic stress disorder, and personality disorders.

The interpretation of the MMPI-II is now fully computerized. The computer is fed with the patients' age, sex, educational level, and marital status and does the rest.

The Millon Clinical Multiaxial Inventory-III (MCMI-III) tests for personality disorders and attendant anxiety and depression. The third edition was formulated in 1996 by Theodore Millon and Roger Davis.

Millon Clinical Multiaxial Inventory. Diagnostic test composed of 157 true-or-false items.

The MCMI-III consists of 24 clinical scales and 3 modifier scales. The modifier scales serve to identify Disclosure (a tendency to hide a pathology or to exaggerate it), Desirability (a bias towards socially desirable responses), and Debasement (endorsing only responses that are highly suggestive of pathology). Next, the Clinical Personality Patterns (scales) which represent mild to moderate pathologies of personality, are: Schizoid, Avoidant, Depressive, Dependent, Histrionic, Narcissistic, Antisocial, Aggressive (Sadistic), Compulsive, Negativistic, and Masochistic. Millon considers only the Schizotypal, Borderline, and Paranoid to be severe personality pathologies and dedicates the next three scales to them.

The last ten scales are dedicated to Axis I and other clinical syndromes: Anxiety Disorder, Somatoform Disorder, Bipolar Manic Disorder, Dysthymic Disorder, Alcohol Dependence, Drug Dependence, Posttraumatic Stress, Thought Disorder, Major Depression, and Delusional Disorder.

Scoring is easy and runs from 0 to 115 per each scale, with 85 and above signifying a pathology. The configuration of the results of all 24 scales provides serious and reliable insights into the tested subject.

The Narcissistic Personality Inventory (NPI) is used to spot narcissistic traits.

The Borderline Personality Organization Scale (BPO) was designed in 1985. It sorts the responses of respondents into 30 relevant scales. It indicates the existence of identity diffusion, primitive defenses, and deficient reality testing.

To these one may add the Personality Diagnostic Questionnaire-IV, the Coolidge Axis II Inventory, the Personality Assessment Inventory (1992), the excellent, literature-based, Dimensional assessment of Personality Pathology, and the comprehensive Schedule of Nonadaptive and Adaptive Personality and Wisconsin Personality Disorders Inventory.

The next diagnostic aim is to understand the way the patient or client functions in relationships, copes with intimacy, and responds to triggers.

The Relationship Styles Questionnaire (RSQ) (1994) contains 30 self-reported items and identifies distinct attachment styles (secure, fearful, preoccupied, and dismissing). The Conflict Tactics Scale (CTS) (1979) is a standardized scale of the frequency and intensity of conflict resolution tactics - especially abusive stratagems - used by members of a dyad (couple).

The Multidimensional Anger Inventory (MAI) (1986) assesses the frequency of angry responses, their duration, magnitude, mode of expression, hostile outlook, and anger-provoking triggers.

The Rorschach Inkblot Test is a diagnostic test comprised of 10 ambiguous inkblots printed on 18X24 cm. cards, in both black and white and color. The cards and the diagnostician's questions provoke free associations in the test subject. These are recorded verbatim together with the inkblot's spatial position and orientation. The patient can then add details and comment on his choices.

Scoring is based on the parts of the cards referred to in the subject's responses (location), the correspondence between the blot and the answers provided (determinant), the content of the responses, how unique or common they are (popularity), how coherent are the patient's narratives (organizational activity), and how well does the patient's percept fit the card (form quality).

The interpretation of the test relies on both the scores obtained and on what we know about mental health disorders. The test teaches the skilled diagnostician how the subject processes information and what is the structure and content of his internal world. These provide meaningful insights into the patient's defenses, reality test, intelligence, fantasy life, and psychosexual make-up.

The Thematic Appreciation Test (TAT) is a diagnostic test comprised of 31 cards. One card is blank and the other thirty include blurred but emotionally powerful (or even disturbing) photographs and drawings. Subjects are asked to tell a story based on the content of the cards. The TAT was developed in 1935 by Morgan and Murray.

The patient's reactions (in the form of brief narratives) are recorded by the tester verbatim. Some examiners prompt the patient to describe the aftermath or outcomes of the stories, but this is a controversial practice.

The TAT is scored and interpreted simultaneously. Murray suggested to identify the hero of each narrative (the figure representing the patient); the inner states and needs of the patient, derived from his or her choices of activities or gratifications; what Murray calls the "press", the hero's environment which imposes constraints on the hero's needs and operations; and the thema, or the motivations developed by the hero in response to all of the above.

The Structured Clinical Interview (SCID-II) was formulated in 1997 by First, Gibbon, Spitzer, Williams, and Benjamin. It is based on the language of criteria for personality disorders in the the DSM-IV. Its 12 groups of questions correspond to the 12 personality disorders. The scoring is simple: either the trait is absent, subthreshold, true, or there is "inadequate information to code".

The SCID-II can be administered to third parties (a spouse, an informant, a colleague) or self-administered (in a reduced format with 119 questions).

The Structured Interview for Disorders of Personality (SIDP-IV) was composed by Pfohl, Blum and Zimmerman in 1997. It also covers the self-defeating personality disorder from the DSM-III. It is conversational and the questions are grouped into 10 topics such as Emotions or Interests and Activities. There is a version of the SIDP-IV in which the questions are grouped by personality disorder. The scoring classifies items as present, subthreshold, present, or strongly present.

Yet, even a complete battery of tests, administered by experienced professionals sometimes fails to identify personality disorders. Such patients are uncanny in their ability to deceive their evaluators.

Paranoid personality disorder

is a psychiatric diagnosis characterized by paranoia and a pervasive, long-standing suspiciousness and generalized mistrust of others. (DSM-IV) For a person's personality to be considered a personality disorder, an enduring pattern of characteristic maladaptive behaviors, thinking and personality traits must be present from the onset of adolescence or early adulthood. Additionally, these behaviors, traits and thinking must be present to the extent that they cause significant difficulties in relationships, employment and other facets of functioning.

Those with paranoid personality disorder are hypersensitive, are easily slighted, and habitually relate to the world by vigilant scanning of the environment for clues or suggestions to validate their prejudicial ideas or biases. They tend to be guarded and suspicious and have quite constricted emotional lives. Their incapacity for meaningful emotional involvement and the general pattern of isolated withdrawal often lend a quality of schizoid isolation to their life experience.

Differential diagnosis:
Because of the surface similarities of the paranoia involved, it is important that the Paranoid Personality Disorder not be confused with paranoid schizophrenia, another totally different type of mental disorder where the patient has constant feelings of being watched, followed or persecuted.

Paranoid personality disorder

The person with a paranoid personality disorder essentially has an ongoing, unjustified suspiciousness and distrust of people. Along with this they are emotionally detached. Some one with this type of disorder will hold beliefs about others:

• suspicion that others are exploiting or deceiving them
• belief that others may not be loyal or trustworthy
• beliefs that there are threats or attacks on their character in innocent statements that others do not see
• holds persistent grudges

It is commonly reported that those with paranoid personality disorders can be very draining to be around, as their constant habit of blame and suspicion makes you feel the need to reassure them on an ongoing basis. Unfortunately when reassurances are made, those with this disorder take this as further evidence that the person mean harm. They tend to drive people away from them, and so have few friends, which they interpret as reinforcing their beliefs that there is a conspiracy against them. This often leads people with this disorder to have a very lonely life.


Extremely sensitive to experiencing failure or rejection

Hold grudges against people and will refuse to forgive insults, injuries or slights

Very suspicious and will often misconstrue the friendly or neutral behaviour of other people as being unfriendly or hostile. Also constantly suspicious about the fidelity of sexual partners

A preoccupation with personal rights and a sense of these being infringed even when this is not so.  Often self centred and self important

Prone to believing in conspiracy theories about events affecting their own lives and in the world at large


Schizoid personality disorder (SPD)
lack of interest in social relationships, seeing no point in sharing time with others

is a personality disorder characterized by a lack of interest in social relationships, a tendency towards a solitary lifestyle, secretiveness, and emotional coldness.[1] SPD is reasonably rare compared with other personality disorders. Its prevalence is estimated at less than 1% of the general population

A Comprehensive Phenomenological Profile

In an article in the American Journal of Psychotherapy, Salman Akhtar, M.D., provides a comprehensive phenomenological profile of Schizoid Personality Disorder in which classic and contemporary descriptive views are synthesized with psychoanalytic observations.

This profile is summarized in a table (reproduced below) listing clinical features, involving six areas of psychosocial functioning and designated by "overt" and "covert" manifestations. Dr. Akhtar states that "these designations do not imply conscious or unconscious but denote seemingly contradictory aspects that are phenomenologically more or less easily discernible," and that "this manner of organizing symptomology emphasizes the centrality of splitting and identity confusion in schizoid personality."


Self-Concept Compliant; stoic; noncompetitive; self-sufficient; lacking assertiveness; feeling inferior and an outsider in life.

Interpersonal Relations: Withdrawn; aloof; have few close friends; impervious to others' emotions; afraid of intimacy.

Social Adaptation: Prefer solitary occupational and recreational activities; marginal or eclectically sociable in groups; vulnerable to esoteric movements owing to a strong need to belong; tend to be lazy and indolent.

Love and Sexuality: Asexual, sometimes celibate; free of romantic interests; averse to sexual gossip and innuendo.

Ethics, Standards, and Ideals: Idiosyncratic moral and political beliefs; tendency towards spiritual, mystical and para-psychological interests.

Cognitive Style: Absent-minded; engrossed in fantasy; vague and stilted speech; alternations between eloquence and inarticulateness.

Self Concept: Cynical; inauthentic; depersonalized; alternately feeling empty, robot-like and full of omnipotent, vengeful fantasies; hidden grandiosity.

Interpersonal Relations Exquisitely sensitive; deeply curious about others; hungry for love; envious of others' spontaneity; intensely needy of involvement with others; capable of excitement with carefully selected intimates.

Social Adaptation  Lack clarity of goals; weak ethnic affiliation; usually capable of steady work; sometimes quite creative and may make unique and original contributions; capable of passionate endurance in certain spheres of interest.

Love and Sexuality  Secret vouyeristic and pornographic interests; vulnerable to erotomania; tendency towards compulsive masturbation and perversions.

Ethics, Standards, and Ideals: Moral unevenness; occasionally strikingly amoral and vulnerable to odd crimes, at other times altruistically self sacrificing.

Cognitive Style Autistic thinking; fluctuations between sharp contact with external reality and hyperreflectiveness about the self; autocentric use of language.

Akhtar, S. Schizoid Personality Disorder: A Synthesis of Developmental, Dynamic, and Descriptive Features. American Journal of Psychotherapy, 151:499-518, 1987.


Schizotypal personality disorder, or simply schizotypal disorder,
is a personality disorder that is characterized by a need for social isolation, odd behavior and thinking, and often unconventional beliefs.

The American Psychiatric Association's DSM-IV-TR, a widely used manual for diagnosing mental disorders, defines Schizotypal personality disorder as "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:

Ideas of reference (excluding delusions of reference)
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)
Unusual perceptual experiences, including bodily illusions
Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped)
Suspiciousness or paranoid ideation
Inappropriate or constricted affect
Behavior or appearance that is odd, eccentric, or peculiar
Lack of close friends or confidants other than first-degree relatives
Social anxiety that tends to be associated with paranoid fears rather than negative judgments about self

There is a high rate of comorbidity with other personality disorders. McGlashan et al. (2000) stated that this may be due to overlapping criteria with other personality disorders, such as avoidant personality disorder and paranoid personality disorder.


Antisocial personality disorder (APD)
"pervasive disregard for the law and the rights of others."

is a mental disorder characterized by a "pervasive pattern of disregard for and violation of the rights of others occuring since the age of 15." It is defined by the American Psychiatric Association's Diagnostic and Statistical Manual: "The essential feature for the diagnosis 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."

Deceit and manipulation are considered essential features of the disorder. Therefore, it is essential in making the diagnosis to collect material from sources other than the individual being diagnosed. Also, the individual must be age 18 or older as well as have a documented history of a conduct disorder before the age of 15. People having antisocial personality disorder are sometimes referred to as "sociopaths" and "psychopaths".

Profile of the Sociopath

Some of the common features of descriptions of the behavior of sociopaths.

Glibness and Superficial Charm

Manipulative and Conning
They never recognize the rights of others and see their self-serving behaviors as permissible. They appear to be charming, yet are covertly hostile and domineering, seeing their victim as merely an instrument to be used. They may dominate and humiliate their victims.

Grandiose Sense of Self
Feels entitled to certain things as "their right."

Pathological Lying
Has no problem lying coolly and easily and it is almost impossible for them to be truthful on a consistent basis. Can create, and get caught up in, a complex belief about their own powers and abilities. Extremely convincing and even able to pass lie detector tests.

Lack of Remorse, Shame or Guilt
A deep seated rage, which is split off and repressed, is at their core. Does not see others around them as people, but only as targets and opportunities. Instead of friends, they have victims and accomplices who end up as victims. The end always justifies the means and they let nothing stand in their way.

Shallow Emotions
When they show what seems to be warmth, joy, love and compassion it is more feigned than experienced and serves an ulterior motive. Outraged by insignificant matters, yet remaining unmoved and cold by what would upset a normal person. Since they are not genuine, neither are their promises.

Incapacity for Love

Need for Stimulation
Living on the edge. Verbal outbursts and physical punishments are normal. Promiscuity and gambling are common.

Callousness/Lack of Empathy
Unable to empathize with the pain of their victims, having only contempt for others' feelings of distress and readily taking advantage of them.

Poor Behavioral Controls/Impulsive Nature
Rage and abuse, alternating with small expressions of love and approval produce an addictive cycle for abuser and abused, as well as creating hopelessness in the victim. Believe they are all-powerful, all-knowing, entitled to every wish, no sense of personal boundaries, no concern for their impact on others.

Early Behavior Problems/Juvenile Delinquency
Usually has a history of behavioral and academic difficulties, yet "gets by" by conning others. Problems in making and keeping friends; aberrant behaviors such as cruelty to people or animals, stealing, etc.

Not concerned about wrecking others' lives and dreams. Oblivious or indifferent to the devastation they cause. Does not accept blame themselves, but blames others, even for acts they obviously committed.

Promiscuous Sexual Behavior/Infidelity
Promiscuity, child sexual abuse, rape and sexual acting out of all sorts.

Lack of Realistic Life Plan/Parasitic Lifestyle
Tends to move around a lot or makes all encompassing promises for the future, poor work ethic but exploits others effectively.

Criminal or Entrepreneurial Versatility
Changes their image as needed to avoid prosecution. Changes life story readily.

Other Related Qualities:

Contemptuous of those who seek to understand them
Does not perceive that anything is wrong with them
Only rarely in difficulty with the law, but seeks out situations where their tyrannical behavior will be tolerated, condoned, or admired
Conventional appearance
Goal of enslavement of their victim(s)
Exercises despotic control over every aspect of the victim's life
Has an emotional need to justify their crimes and therefore needs their victim's affirmation (respect, gratitude and love)
Ultimate goal is the creation of a willing victim
Incapable of real human attachment to another
Unable to feel remorse or guilt
Extreme narcissism and grandiose
May state readily that their goal is to rule the world

(The above traits are based on the psychopathy checklists of H. Cleckley and R. Hare.)

NOTE: In the 1830's this disorder was called "moral insanity." By 1900 it was changed to "psychopathic personality." More recently it has been termed "antisocial personality disorder" in the DSM-III and DSM-IV. Some critics have complained that, in the attempt to rely only on 'objective' criteria, the DSM has broadened the concept to include too many individuals. The APD category includes people who commit illegal, immoral or self-serving acts for a variety of reasons and are not necessarily psychopaths.

DSM-IV Definition

Antisocial personality disorder is characterized by a lack of regard for the moral or legal standards in the local culture. There is a marked inability to get along with others or abide by societal rules. Individuals with this disorder are sometimes called psychopaths or sociopaths.

Diagnostic Criteria (DSM-IV)

1. Since the age of fifteen there has been a disregard for and violation of the right's of others, those right's considered normal by the local culture, as indicated by at least three of the following:
    A. Repeated acts that could lead to arrest.
    B. Conning for pleasure or profit, repeated lying, or the use of aliases.
    C. Failure to plan ahead or being impulsive.
    D. Repeated assaults on others.
    E. Reckless when it comes to their or others safety.
    F. Poor work behavior or failure to honor financial obligations.
    G. Rationalizing the pain they inflict on others.

2. At least eighteen years in age.

3. Evidence of a Conduct Disorder, with its onset before the age of fifteen.

4. Symptoms not due to another mental disorder.

Antisocial Personality Disorder Overview
(Written by Derek Wood, RN, BSN, PhD Candidate)

Antisocial Personality Disorder results in what is commonly known as a Sociopath. The criteria for this disorder require an ongoing disregard for the rights of others, since the age of 15 years. Some examples of this disregard are reckless disregard for the safety of themselves or others, failure to conform to social norms with respect to lawful behaviors, deceitfulness such as repeated lying or deceit for personal profit or pleasure, and lack of remorse for actions that hurt other people in any way. Additionally, they must have evidenced a Conduct Disorder before the age of 15 years, and must be at least 18 years old to receive this diagnosis.

People with this disorder appear to be charming at times, and make relationships, but to them, these are relationships in name only. They are ended whenever necessary or when it suits them, and the relationships are without depth or meaning, including marriages. They seem to have an innate ability to find the weakness in people, and are ready to use these weaknesses to their own ends through deceit, manipulation, or intimidation, and gain pleasure from doing so.

They appear to be incapable of any true emotions, from love to shame to guilt. They are quick to anger, but just as quick to let it go, without holding grudges. No matter what emotion they state they have, it has no bearing on their future actions or attitudes.

They rarely are able to have jobs that last for any length of time, as they become easily bored, instead needing constant change. They live for the moment, forgetting the past, and not planning the future, not thinking ahead what consequences their actions will have. They want immediate rewards and gratification. There currently is no form of psychotherapy that works with those with antisocial personality disorder, as those with this disorder have no desire to change themselves, which is a prerequisite. No medication is available either. The only treatment is the prevention of the disorder in the early stages, when a child first begins to show the symptoms of conduct disorder.

THE PSYCHOPATH NEXT DOOR (Source: http://chericola57.tripod.com/infinite.html)

Psychopath. We hear the word and images of Bernardo, Manson and Dahmer pop into our heads; no doubt Ted Bundy too. But they're the bottom of the barrel -- most of the two million psychopaths in North America aren't murderers. They're our friends, lovers and co-workers. They're outgoing and persuasive, dazzling you with charm and flattery. Often you aren't even aware they've taken you for a ride -- until it's too late.

Psychopaths exhibit a Jekyll and Hyde personality. "They play a part so they can get what they want," says Dr. Sheila Willson, a Toronto psychologist who has helped victims of psychopaths. The guy who showers a woman with excessive attention is much more capable of getting her to lend him money, and to put up with him when he strays. The new employee who gains her co-workers' trust has more access to their chequebooks. And so on. Psychopaths have no conscience and their only goal is self-gratification. Many of us have been their victims -- at work, through friendships or relationships -- and not one of us can say, "a psychopath could never fool me."

Think you can spot one? Think again. In general, psychopaths aren't the product of broken homes or the casualties of a materialistic society. Rather they come from all walks of life and there is little evidence that their upbringing affects them. Elements of a psychopath's personality first become evident at a very early age, due to biological or genetic factors. Explains Michael Seto, a psychologist at the Centre for Addiction and Mental health in Toronto, by the time that a person hits their late teens, the disorder is almost certainly permanent. Although many clinicians use the terms psychopath and sociopath interchangeably, writes psychopath expert Robert Hare on his book 'Without Conscience', a sociopath's criminal behavior is shaped by social forces and is the result of a dysfunctional environment.

Psychopaths have only a shallow range of emotions and lack guilt, says Hare. They often see themselves as victims, and lack remorse or the ability to empathize with others. "Psychopaths play on the fact that most of us are trusting and forgiving people," adds Seto. The warning signs are always there; it's just difficult to see them because once we trust someone, the friendship becomes a blinder.

Even lovers get taken for a ride by psychopaths. For a psychopath, a romantic relationship is just another opportunity to find a trusting partner who will buy into the lies. It's primarily why a psychopath rarely stays in a relationship for the long term, and often is involved with three or four partners at once, says Willson. To a psychopath, everything about a relationship is a game. Willson refers to the movie 'Sliding Doors' to illustrate her point. In the film, the main character comes home early after just having been fired from her job. Only moments ago, her boyfriend has let another woman out the front door. But in a matter of minutes he is the attentive and concerned boyfriend, taking her out to dinner and devoting the entire night to comforting her. All the while he's planning to leave the next day on a trip with the other woman.

The boyfriend displays typical psychopathic characteristics because he falsely displays deep emotion toward the relationship, says Willson. In reality, he's less concerned with his girlfriend's depression than with making sure she's clueless about the other woman's existence. In the romance department, psychopaths have an ability to gain your affection quickly, disarming you with words, intriguing you with grandiose plans. If they cheat you'll forgive them, and one day when they've gone too far, they'll leave you with a broken heart (and an empty wallet). By then they'll have a new player for their game.

The problem with their game is that we don't often play by their rules. Where we might occasionally tell a white lie, a psychopath's lying is compulsive. Most of us experience some degree of guilt about lying, preventing us from exhibiting such behavior on a regular basis. "Psychopaths don't discriminate who it is they lie to or cheat," says Seto. "There's no distinction between friend, family and sucker."

No one wants to be the sucker, so how do we prevent ourselves from becoming close friends or getting into a relationship with a psychopath? It's really almost impossible, say Seto and Willson. Unfortunately, laments Seto, one way is to become more suspicious and less trusting of others. Our tendency is to forgive when we catch a loved one in a lie. "Psychopaths play on this fact," he says. "However, I'm certainly not advocating a world where if someone lies once or twice, you never speak to them again." What you can do is look at how often someone lies and how they react when caught. Psychopaths will lie over and over again, and where other people would sincerely apologize, a psychopath may apologize but won't stop.

Psychopaths also tend to switch jobs as frequently as they switch partners, mainly because they don't have the qualities to maintain a job for the long haul. Their performance is generally erratic, with chronic absences, misuse of company resources and failed commitments. Often they aren't even qualified for the job and use fake credentials to get it. Seto talks of a patient who would get marketing jobs based on his image; he was a presentable and charming man who layered his conversations with educational and occupational references. But it became evident that the man hadn't a clue what he was talking about, and was unable to hold down a job.

How do you make sure you don't get fooled when you're hiring someone to baby-sit your child or for any other job? Hire based on reputation and not image, says Willson. Check references thoroughly. Psychopaths tend to give vague and inconsistent replies. Of course the best way to solve this problem would be to cure psychopaths of their 'illness.' But there's no recipe for treating them, say psychiatrists. Today's traditional methods of psychotherapy (psychoanalysis, group and one-on-one therapy) and drug treatments have failed. Therapy is more likely to work when an individual admits there's a problem and wants to change. The common problem with psychopaths, says Sets, "Is they don't see a problem with their behavior."

Psychopaths don't seek therapy willingly, says Seto. Rather, they're pushed into it by a desperate relative or by a court order. To a psychopath, a therapist is just one more person who must be conned, and the psychopath plays the part right until the therapist is convinced of his or her 'rehabilitation.'

Even though we can't treat psychopaths effectively with therapy, it doesn't mean we can't protect ourselves, writes Hare. Willson agrees, citing the most important factor in keeping psychopaths at bay is to know your vulnerabilities. We need to "realize our own potential and maximize our strengths" so that our insecurities don't overcome us. Because, she says, a psychopath is a chameleon who becomes "an image of what you haven't done for yourself." Over time, she says, "their appearance of perfection will begin to crack," but by that time you will have been emotionally and perhaps financially scathed. There comes a time when you realize there's no point in searching for answers; the only thing is to move on.

Taken in part from MW -- By Caroline Konrad -- September 1999


These people are mentally ill and extremely dangerous! The following precautions will help to protect you from the destructive acts of which they are capable.

First, to recognize them, keep the following guidelines in mind.

(1) They are habitual liars. They seem incapable of either knowing or telling the truth about anything.

(2) They are egotistical to the point of narcissism. They really believe they are set apart from the rest of humanity by some special grace.

(3) They scapegoat; they are incapable of either having the insight or willingness to accept responsibility for anything they do. Whatever the problem, it is always someone else's fault.

(4) They are remorselessly vindictive when thwarted or exposed.

(5) Genuine religious, moral, or other values play no part in their lives. They have no empathy for others and are capable of violence. Under older psychological terminology, they fall into the category of psychopath or sociopath, but unlike the typical psychopath, their behavior is masked by a superficial social facade.

If you have come into conflict with such a person or persons, do the following immediately!

(1) Notify your friends and relatives of what has happened.

Do not be vague. Name names, and specify dates and circumstances. Identify witnesses if possible and provide supporting documentation if any is available.

(2) Inform the police. The police will do nothing with this information except to keep it on file, since they are powerless to act until a crime has been committed. Unfortunately, that often is usually too late for the victim. Nevertheless, place the information in their hands.

Obviously, if you are assaulted or threatened before witnesses, you can get a restraining order, but those are palliative at best.

(3) Local law enforcement agencies are usually under pressure if wealthy or politically powerful individuals are involved, so include state and federal agencies as well and tell the locals that you have. In my own experience, one agency that can help in a pinch is the Criminal Investigation Division of the Internal Revenue Service or (in Canada) Victims Services at your local police unit. It is not easy to think of the IRS as a potential friend, but a Swedish study showed that malignant types (the Swedes called them bullies) usually commit some felony or other by the age of twenty. If the family is wealthy, the fact may never come to light, but many felonies involve tax evasion, and in such cases, the IRS is interested indeed. If large amounts of money are involved, the IRS may solve all your problems for you. For obvious reasons the Drug Enforcement Agency may also be an appropriate agency to approach. The FBI is an important agency to contact, because although the FBI does not have jurisdiction over murder or assault, if informed, they do have an active interest in any other law enforcement agencies that do not follow through with an honest investigation and prosecution should a murder occur. Civil rights are involved at that point. No local crooked lawyer, judge, or corrupt police official wants to be within a country mile if that comes to light! It is in such cases that wealthy psychopaths discover just how firm the "friends" they count on to cover up for them really are! Even some of the drug cartel biggies will scuttle for cover if someone picks up the brick their thugs hide under. Exposure is bad for business.

(4) Make sure that several of your friends have the information in the event something happens to you. That way, an appropriate investigation will follow if you are harmed. Don't tell other people who has the information, because then something bad could happen to them as well. Instruct friends to take such an incident to the newspapers and other media.

If you are dealing with someone who has considerable money, you must realize that they probably won't try to harm you themselves, they will contract with someone to make the hit. The malignant type is a coward and will not expose himself or herself to personal danger if he or she can avoid it.


Borderline personality disorder (BPD),
extreme "black and white" thinking, instability in relationships, self-image, identity and behavior

is a psychiatric diagnosis, a diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders (published by the American Psychiatric Association) that describes a long-term disturbance of personality function characterized by depth and variability of moods. It is one of four related diagnoses classified as cluster B ("dramatic-erratic") personality disorders typified by disturbances in impulse control and emotional dysregulation, the others being narcissistic, histrionic, and antisocial personality disorders.

Disturbances suffered by those with borderline personality disorder are wide-ranging. The general profile of the disorder typically includes a pervasive instability in mood; extreme "black and white" thinking, or "splitting"; chaotic and unstable interpersonal relationships, self-image, identity, and behavior; as well as a disturbance in the individual's sense of self. In extreme cases, this disturbance in the sense of self can lead to periods of dissociation.

These disturbances have a pervasive negative impact on many or all of the psychosocial facets of life. This includes the inability to maintain relationships in work, home, and social settings. Common comorbid conditions are Axis I disorders such as substance abuse, depression and other mood disorders. Attempted suicide and completed suicide are possible outcomes without proper care and effective therapy.

Onset of symptoms typically occurs during adolescence or young adulthood, which persist for about a decade; while this period can be trying on the patient, their support system and their therapists, the majority of cases lessen in severity over time.

As with other mental disorders, the causes of BPD are complex and unknown. One finding in the search for causation in the disorder is a history of childhood trauma (possibly child sexual abuse), although other researchers have suggested diverse possible causes, such as a genetic predisposition, neurobiological factors, environmental factors or brain abnormalities. Neurobiological research has highlighted some abnormalities in serotonin metabolism. The incidence of BPD has been calculated as 1 to 3 percent of the American adult population. Alternatively, it has been calculated as 2 percent of the population composed mostly of young women and accounts for 20 percent of psychiatric hospitalizations.

The mainstay of treatment are various forms of psychotherapy. In general, medication and talk therapy are methods of treating borderline personality disorder.[

The term borderline, although it was used as early as the 17th century to describe this condition, was employed by Adolph Stern in 1938 to describe a condition as being on the borderline between neurosis and psychosis. Because the term no longer reflects current thinking, there is an ongoing debate concerning whether this disorder should be renamed.

Borderline personality disorder is frequently comorbid with other psychological disorders, particularly the Cluster-B personality disorders.


According to the DSM IV (Diagnostic and Statistical Manual of Mental Disorders 4th Edition) ‘A person who suffers from borderline personality disorder has labile interpersonal relationships characterised by instability. This pattern of interacting with others has persisted for years and is usually closely related to the person’s self image and early social interactions. The pattern is present in a variety of settings (e.g. not just at work or home) and is often accompanied by a similar lability (fluctuating back and forth, sometimes in a quick manner) in a person’s affect [mood] or feelings. Relationships and the person’s affect may often be characterised as being shallow. A person with this disorder may also exhibit impulsive behaviours and exhibit a majority of the following symptoms:

1. Frantic efforts to avoid real or imagined abandonment

2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

3. Identity disturbance: markedly and persistently unstable self-image or sense of self

4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating)

5. Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour

6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days)

7. Chronic feelings of emptiness

8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

9. Transient, stress-related paranoid ideation or severe dissociative symptoms

Anyone with six or more of the above traits and symptoms may be diagnosed with Borderline Personality Disorder. However, the traits must be long-standing (pervasive) and there must be no better explanation for them (for example a physical illness, another mental illness or substance misuse).


The ICD (International Classification of Diseases) also has a description of BPD. The ICD 10 calls the disorder by its European name ‘emotionally unstable personality disorder. The ICD describe BPD as a:

‘Personality disorder characterized by a definite tendency to act impulsively and without consideration of the consequences; the mood is unpredictable and capricious. There is a liability to outbursts of emotion and incapacity to control the behavioural explosions. There is a tendency to quarrelsome behaviour and to conflicts with others, especially when impulsive acts are thwarted or censored. Two types may be distinguished: the impulsive type, characterized predominantly by emotional instability and lack of impulse control, and the borderline type, characterized in addition by disturbances in self-image, aims, and internal preferences, by chronic feelings of emptiness, by intense and unstable interpersonal relationships, and by a tendency to self-destructive behaviour, including suicide gestures and attempts.’
(www.who.int/classifications 2005)


A person with a borderline personality disorder often experiences a repetitive pattern of disorganization and instability in self-image, mood, behavior and close personal relationships. This can cause significant distress or impairment in friendships and work. A person with this disorder can often be bright and intelligent, and appear warm, friendly and competent. They sometimes can maintain this appearance for a number of years until their defense structure crumbles, usually around a stressful situation like the breakup of a romantic relationship or the death of a parent.

Relationships with others are intense but stormy and unstable with marked shifts of feelings and difficulties in maintaining intimate, close connections. The person may manipulate others and often has difficulty with trusting others. There is also emotional instability with marked and frequent shifts to an empty lonely depression or to irritability and anxiety. There may be unpredictable and impulsive behavior which might include excessive spending, promiscuity, gambling, drug or alcohol abuse, shoplifting, overeating or physically self-damaging actions such as suicide gestures. The person may show inappropriate and intense anger or rage with temper tantrums, constant brooding and resentment, feelings of deprivation, and a loss of control or fear of loss of control over angry feelings. There are also identity disturbances with confusion and uncertainty about self-identity, sexuality, life goals and values, career choices, friendships. There is a deep-seated feeling that one is flawed, defective, damaged or bad in some way, with a tendency to go to extremes in thinking, feeling or behavior. Under extreme stress or in severe cases there can be brief psychotic episodes with loss of contact with reality or bizarre behavior or symptoms. Even in less severe instances, there is often significant disruption of relationships and work performance. The depression which accompanies this disorder can cause much suffering and can lead to serious suicide attempts.

It is a common disorder with estimates running as high as 10-14% of the general population. The frequency in women is two to three times greater than men. This may be related to genetic or hormonal influences. An association between this disorder and severe cases of premenstrual tension has been postulated. Women commonly suffer from depression more often than men. The increased frequency of borderline disorders among women may also be a consequence of the greater incidence of incestuous experiences during their childhood. This is believed to occur ten times more often in women than in men, with estimates running to up to one-fourth of all women. This chronic or periodic victimization and sometimes brutalization can later result in impaired relationships and mistrust of men and excessive preoccupation with sexuality, sexual promiscuity, inhibitions, deep-seated depression and a seriously damaged self-image. There may be an innate predisposition to this disorder in some people. Because of this there may ensue subsequent failures in development in the relationship between mother and infant particularly during the separation and identity-forming phases of childhood.

Treatment includes psychotherapy which allows the patient to talk about both present difficulties and past experiences in the presence of an empathetic, accepting and non-judgemental therapist. The therapy needs to be structured, consistent and regular, with the patient encouraged to talk about his or her feelings rather than to discharge them in his or her usual self-defeating ways. Sometimes medications such as antidepressants, lithium carbonate, or antipsychotic medication are useful for certain patients or during certain times in the treatment of individual patients. Treatment of any alcohol or drug abuse problems is often mandatory if the therapy is to be able to continue. Brief hospitalization may sometimes be necessary during acutely stressful episodes or if suicide or other self-destructive behavior threatens to erupt. Hospitalization may provide a a temporary removal from external stress. Outpatient treatment is usually difficult and long-term - sometimes over a number of years. The goals of treatment could include increased self-awareness with greater impulse control and increased stability of relationships. A positive result would be in one's increased tolerance of anxiety. Therapy should help to alleviate psychotic or mood-disturbance symptoms and generally integrate the whole personality. With this increased awareness and capacity for self-observation and introspection, it is hoped the patient will be able to change the rigid patterns tragically set earlier in life and prevent the pattern from repeating itself in the next generational cycle.

The Facts
• Three quarters of people with BPD are female and usually within childbearing age.
• 70 to 80 % of patients meeting the diagnostic criteria for BPD self mutilate or self harm.
• One in ten BPD sufferers successfully completes a suicide attempt.
• BPD patients are recognised as responding poorly to treatment.
• BPD patients are generally thought to have a long term, poor quality of life.
• BPD has been associated with other conditions such as schizophrenia, several types of psychosis, other affective disorders and epilepsy.
• Very little research has been conducted to investigate BPD in men.
• BPD sufferers are reported to be very frequent users of mental health resources.
• Men with BPD compared with men suffering from other personality disorders have shown more evidence of dissociation, image distortion, frequency of childhood sexual abuse experiences, longer experiences of physical abuse and experiences of loss at an early age.
• Research suggests that male BPD patients are more regularly diagnosed with substance abuse problems than female BPD patients are.
• Only two personality disorders are associated with self-harm behaviour. One is BPD and the other is antisocial behaviour disorder.
• People who have BPD are more likely to self-harm for two reasons: a) as a response to impulsive urges and b) as part of a suicidal gesture.
• Research suggests that people with BPD frequently suffer from identity and interpersonal issues.
• At least 50% of BPD sufferers also suffer form major depressive disorder, dysthymia, or even both.
• It is very difficult to say weather a person with BPD's condition will change over time. Research has suggested that some people’s symptoms improve, some get worse and some remain unchanged.
• 11% of diagnosed BPD patients are treated in outpatient clinics.
• 20% of BPD patients spend time in psychiatric hospital.
• Between 40% and 70% of BPD patients report having been sexually abused, often by a non-care giver.
• Clinicians are often wrongly educated or under educated about BPD and BPD treatments.
• Approximately 2% of the population are affected by BPD.


Histrionic Personality Disorder
Melissa Arthur LCSW MA

Histrionic personality disorder (HPD): pervasive attention-seeking behavior including inappropriate sexual seductiveness and shallow or exaggerated emotions, it is a personality disorder characterized by a pattern of excessive emotionality and attention-seeking, including an excessive need for approval and inappropriate seductiveness, usually beginning in early adulthood.

The essential feature of histrionic personality disorder is an excessive pattern of emotionality and attention-seeking behavior. These individuals are lively, dramatic, enthusiastic, and flirtatious. They may be inappropriately sexually provocative, express strong emotions with an impressionistic style, and be easily influenced by others.

A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

is uncomfortable in situations in which he or she is not the center of attention
interaction with others is often characterized by inappropriate sexually seductive or provocative behavior
displays rapidly shifting and shallow expression of emotions
consistently uses physical appearance to draw attention to self
has a style of speech that is excessively impressionistic and lacking in detail
shows self-dramatization, theatricality, and exaggerated expression of emotion
is suggestible, i.e., easily influenced by others or circumstances
considers relationships to be more intimate than they actually are

Researchers have found that HPD appears primarily in men and women with above-average physical appearances. Some research has suggested that the connection between HPD and physical appearance holds for women rather than for men.

Both women and men with HPD express a strong need to be the center of attention. Individuals with HPD exaggerate, throw temper tantrums, and cry if they are not the center of attention. Patients with HPD are naive, gullible, have a low frustration threshold, and strong dependency needs.
A condition with onset at or before adolescence characterized by persistent patterns of dysfunctional behavior (excessive emotionality & attention seeking) deviating from one's culture and social environment that lead to functional impairment and distress to the individual and those who have regular interaction with the individual.
Behaviors are perceived by the patient to be "normal" and "right" and they have little insight as to their responsibility for these behaviors.
Condition is classified based on the predominant symptoms and their severity.
Cluster B Personality Disorder (inclusive of antisocial, borderline, histrionic and narcissistic personality disorders) characterized by a pervasive pattern of excessive emotionality and attention seeking, present in a variety of contexts (5 or more symptom patterns to diagnose) (1C):
Shows self-dramatization, theatricality, and exaggerated expressions of emotion
Is suggestible, i.e., easily influenced by others or circumstances
Uncomfortable when not center of attention
Interaction with others is often characterized by inappropriate sexually seductive behavior
Rapidly shifting and shallow expression of emotion
Draws attention through physical appearance
Has a style of speech that is excessively impressionistic and lacks detail
Considers relationships more intimate than they are (1C)

Histrionic Personality Disorder Phases of Formulation and Treatment
Clarifying Symptomatic Phenomena and Establishing a Therapeutic Alliance
Identifying and Dealing With Shifts in State of Mind
Identifying and Counteracting Defensive Control Processes
Identifying and Helping the Patient to Modify Irrational Beliefs & Contradictions in Schemas of Self
Starts in adolescence and early twenties and persists throughout one's life in the absence of treatment.(1C)

2-3% general population(1C)
Tends to be identified more frequently in females(1C)

Risk Factors
Major character traits may be inherited
Other character traits due to a combination of genetics and environment including adverse childhood experiences
High-risk populations
Individuals who have experienced pervasive trauma during childhood have been shown to be at a greater risk for developing HPD as well as for developing other personality disorders.

Cross-cultural issues
HPD may be diagnosed more frequently in Hispanic and Latin-American cultures and less frequently in Asian cultures. Further research is needed on the effects of culture upon the symptoms of HPD.

Environmental and genetic factors including adverse childhood experiences including lack of parental attention.

There is a lack of research on the causes of HPD. Even though the causes for the disorder are not definitively known, it is thought that HPD may be caused by biological, developmental, cognitive, and social factors.

Studies show that patients with HPD have highly responsive noradrenergic systems, the mechanisms surrounding the release of a neurotransmitter called norepinephrine. Neurotransmitters are chemicals that communicate impulses from one nerve cell to another in the brain, and these impulses dictate behavior. The tendency towards an excessively emotional reaction to rejection, common among patients with HPD, may be attributed to a malfunction in a group of neurotransmitters called catecholamines. (Norepinephrine belongs to this group of neurotransmitters.)

 Psychoanalytic theory, developed by Freud, outlines a series of psychosexual stages of development through which each individual passes. These stages determine an individual's later psychological development as an adult. Early psychoanalysts proposed that the genital phase, Freud's fifth or last stage of psychosexual development, is a determinant of HPD. Later psychoanalysts considered the oral phase, Freud's first stage of psychosexual development, to be a more important determinant of HPD. Most psychoanalysts agree that a traumatic childhood contributes towards the development of HPD. Some theorists suggest that the more severe forms of HPD derive from disapproval in the early mother-child relationship.

Another component of Freud's theory is the defense mechanism. Defense mechanisms are sets of systematic, unconscious methods that people develop to cope with conflict and to reduce anxiety. According to Freud's theory, all people use defense mechanisms, but different people use different types of defense mechanisms. Individuals with HPD differ in the severity of the maladaptive defense mechanisms they use. Patients with more severe cases of HPD may utilize the defense mechanisms of repression, denial, and dissociation.

Repression is the most basic defense mechanism. When patients' thoughts produce anxiety or are unacceptable to them, they use repression to bar the unacceptable thoughts or impulses from consciousness.

Patients who use denial may say that a prior problem no longer exists, suggesting that their competence has increased; however, others may note that there is no change in the patients' behaviors.

When patients with HPD use the defense mechanism of dissociation, they may display two or more personalities. These two or more personalities exist in one individual without integration. Patients with less severe cases of HPD tend to employ displacement and rationalization as defenses.

Displacement occurs when a patient shifts an affect from one idea to another. For example, a man with HPD may feel angry at work because the boss did not consider him to be the center of attention. The patient may displace his anger onto his wife rather than become angry at his boss.

Rationalization occurs when individuals explain their behaviors so that they appear to be acceptable to others.

A biosocial model in psychology asserts that social and biological factors contribute to the development of personality. Biosocial learning models of HPD suggest that individuals may acquire HPD from inconsistent interpersonal reinforcement offered by parents. Proponents of biosocial learning models indicate that individuals with HPD have learned to get what they want from others by drawing attention to themselves.

 Studies of specific cultures with high rates of HPD suggest social and cultural causes of HPD. For example, some researchers would expect to find this disorder more often among cultures that tend to value uninhibited displays of emotion.

Researchers have found some connections between the age of individuals with HPD and the behavior displayed by these individuals. The symptoms of HPD are long-lasting; however, histrionic character traits that are exhibited may change with age. For example, research suggests that seductiveness may be employed more often by a young adult than by an older one. To impress others, older adults with HPD may shift their strategy from sexual seductiveness to a paternal or maternal seductiveness. Some histrionic symptoms such as attention-seeking, however, may become more apparent as an individual with HPD ages.

Associated Conditions

• Depression
• Anxiety disorders
• Panic disorder
• Somatization disorders
• Body dysmorphic disorder (strong emphasized on physical appearance)
• Anorexia
• Post traumatic stress disorder including dissociative disorders
• Substance abuse
• Other psychiatric disorders in patient and family members.

The diagnosis of HPD is complicated because it may seem like many other disorders, and also because it commonly occurs simultaneously with other personality disorders. The 1994 version of the DSM introduced the criterion of suggestibility and the criterion of overestimation of intimacy in relationships to further refine the diagnostic criteria set of HPD, so that it could be more easily recognizable. Prior to assigning a diagnosis of HPD, clinicians need to evaluate whether the traits evident of HPD cause significant distress. (The DSMrequires that the symptoms cause significant distress in order to be considered a disorder.) The diagnosis of HPD is frequently made on the basis of an individual's history and results from unstructured and semi-structured interviews.

Signs and symptoms
Distress, excessive emotionality (2C)
Impairment of social and/or occupational functioning(2C)
Not due to direct physiological effects of substance abuse, drug abuse, medication use or general medical conditions.

DSM-IV-TRlists eight symptoms that form the diagnostic criteria for HPD:

• Center of attention: Patients with HPD experience discomfort when they are not the center of attention.
• Sexually seductive: Patients with HPD displays inappropriate sexually seductive or provocative behaviors towards others.
• Shifting emotions: The expression of emotions of patients with HPD tends to be shallow and to shift rapidly.
• Physical appearance: Individuals with HPD consistently employ physical appearance to gain attention for themselves.
• Speech style: The speech style of patients with HPD lacks detail. Individuals with HPD tend to generalize, and when these individuals speak, they aim to please and impress.
• Dramatic behaviors: Patients with HPD display self-dramatization and exaggerate their emotions.
• Suggestibility: Other individuals or circumstances can easily influence patients with HPD.
• Overestimation of intimacy: Patients with HPD overestimate the level of intimacy in a relationship.

Comprehensive interview and mental status examination
Family session to assess persistent pattern of behavior


Psychological testing, e.g., MMPI-II


CT scan and MRI of the brain may be necessary in newly developed symptoms in the absence of a triggering event to rule out the rare instance of organic brain disease.

Differential diagnosis is the process of distinguishing one mental disorder from other similar disorders. For example, at times, it is difficult to distinguish between HPD and borderline personality disorder. Suicide attempts, identity diffusion, and numerous chaotic relationships occur less frequently, however, with a diagnosis of HPD. Another example of overlap can occur between HPD and dependent personality disorder. Patients with HPD and dependent personality disorder share high dependency needs, but only dependent personality disorder is linked to high levels of self-attributed dependency needs. Whereas patients with HPD tend to be active and seductive, individuals with dependent personality disorder tend to be subservient in their demeanor.

Psychological measures
In addition to the interviews mentioned previously, self-report inventories and projective tests can also be used to help the clinician diagnose HPD. The Minnesota Multiphasic Personality Inventory-2 (MMPI-2) and the Millon Clinical Mutiaxial Inventory-III (MCMI-III) are self-report inventories with a lot of empirical support. Results of intelligence examinations for individuals with HPD may indicate a lack of perseverance on arithmetic or on tasks that require concentration.

In patients who have attempted overdose, transport all appropriate pill bottles to hospital

Appropriate psychiatric security measures should be in place to prevent lethality.
General Measures

Emphasize importance of basic nutritional guidelines. No known special diet.

Exercise as a means of reducing stress.

Psychodynamic therapy
HPD, like other personality disorders, may require several years of therapy and may affect individuals throughout their lives. Some professionals believe that psychoanalytic therapy is a treatment of choice for HPD because it assists patients to become aware of their own feelings. Long-term psychodynamic therapy needs to target the underlying conflicts of individuals with HPD and to assist patients in decreasing their emotional reactivity. Therapists work with thematic dream material related to intimacy and recall. Individuals with HPD may have difficulty recalling because of their tendency to repress material.

Cognitive-behavioral therapy
Cognitive therapy is a treatment directed at reducing the dysfunctional thoughts of individuals with HPD. Such thoughts include themes about not being able to take care of oneself. Cognitive therapy for HPD focuses on a shift from global, suggestible thinking to a more methodical, systematic, and structured focus on problems. Cognitive-behavioral training in relaxation for an individual with HPD emphasizes challenging automatic thoughts about inferiority and not being able to handle one's life. Cognitive-behavioral therapy teaches individuals with HPD to identify automatic thoughts, to work on impulsive behavior, and to develop better problem-solving skills. Behavioral therapists employ assertiveness training to assist individuals with HPD to learn to cope using their own resources. Behavioral therapists use response cost to decrease the excessively dramatic behaviors of these individuals. Response cost is a behavioral technique that involves removing a stimulus from an individual's environment so that the response that directly precedes the removal is weakened. Behavioral therapy for HPD includes techniques such as modeling and behavioral rehearsal to teach patients about the effect of their theatrical behavior on others in a work setting.

Group therapy
Group therapy is suggested to assist individuals with HPD to work on interpersonal relationships. Psychodrama techniques or group role play can assist individuals with HPD to practice problems at work and to learn to decrease the display of excessively dramatic behaviors. Using role-playing, individuals with HPD can explore interpersonal relationships and outcomes to understand better the process associated with different scenarios. Group therapists need to monitor the group because individuals with HPD tend to take over and dominate others.

Family therapy
To teach assertion rather than avoidance of conflict, family therapists need to direct individuals with HPD to speak directly to other family members. Family therapy can support family members to meet their own needs without supporting the histrionic behavior of the individual with HPD who uses dramatic crises to keep the family closely connected. Family therapists employ behavioral contracts to support assertive behaviors rather than temper tantrums.

No known drug to treat personality disorder, however, medications can reduce symptoms (3C) associated with the Axis I Disorders such as Mood disorders (Anti-depressants: SSRIs) and Anxiety disorders (Anxiolytics: benzodiazepines, buspirone, and the SSRIs) (3C)
Pharmacotherapy is not a treatment of choice for individuals with HPD unless HPD occurs with another disorder. For example, if HPD occurs with depression, antidepressants may be prescribed. Medication needs to be monitored for abuse.

Alternative therapies
Meditation has been used to assist extroverted patients with HPD to relax and to focus on their own inner feelings. Some therapists employ hypnosis to assist individuals with HPD to relax when they experience a fast heart rate or palpitations during an expression of excessively dramatic, emotional, and excitable behavior.

Many people with this disorder are able to function well socially and at work. Those with severe cases, however, might experience significant problems in their daily lives.

The personality characteristics of individuals with HPD are long-lasting. Individuals with HPD utilize medical services frequently, but they usually do not stay in psychotherapeutic treatment long enough to make changes. They tend to set vague goals and to move toward something more exciting. Treatment for HPD can take a minimum of one to three years and tends to take longer than treatment for disorders that are not personality disorders, such as anxiety disorders or mood disorders.

As individuals with HPD age, they display fewer symptoms. Some research suggests that the difference between older and younger individuals may be attributed to the fact that older individuals have less energy.

Research indicates that a relationship exists between poor treatment outcomes and premature termination from treatment for individuals with Cluster B personality disorders. Some researchers suggest that studies that link HPD to continuation in treatment need to consider the connection between overestimates of intimacy and premature termination from therapy.

Although prevention of the disorder might not be possible, treatment can allow a person who is prone to this disorder to learn more productive ways of dealing with situations.

Early diagnosis can assist patients and family members to recognize the pervasive pattern of reactive emotion among individuals with HPD. Educating people, particularly mental health professionals, about the enduring character traits of individuals with HPD may prevent some cases of mild histrionic behavior from developing into full-blown cases of maladaptive HPD. Further research in prevention needs to investigate the relationship between variables such as age, gender, culture, and ethnicity and HPD.

• Unstable relationships with family, friends and coworkers.
• May be characterized by separations and divorces
• Disruptive work patterns (e.g. absenteeism, frequent job changes and decreased productivity)
• Increased demand for outpatient medical visits due to psychological condition andattention seeking behavior

Patient monitoring
If the patient is on a pharmacological regime, initial monitoring should be frequent (every 2 weeks) to evaluate the effectiveness, potential side effects of medication, and suicidal ideation.
In the absence of pharmacological treatment, frequent regular visits (every 4-6 weeks) will help prevent attention-seeking phone calls/visits.

American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th ed). Washington DC: American Psychiatric Association.
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Narcissistic Personality Disorder
(NPD) a pervasive pattern of grandiosity, need for admiration, and a lack of empathy"

is a personality disorder defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM IV-R), the diagnostic classification system used in the United States, as "a pervasive pattern of grandiosity, need for admiration, and a lack of empathy."

The narcissist is described as turning inward for gratification rather than depending on others and as being excessively preoccupied with issues of personal adequacy, power and prestige.

Narcissistic Personality Disorder

While grandiosity is the diagnostic hallmark of pathological narcissism, there is research evidence that pathological narcissism occurs in two forms, (a) a grandiose state of mind in young adults that can be corrected by life experiences, and (b) the stable disorder described in DSM-IV, which is defined less by grandiosity than by severely disturbed interpersonal relations.

The preferred theory seems to be that narcissism is caused by very early affective deprivation, yet the clinical material tends to describe narcissists as unwilling rather than unable, thus treating narcissistic behaviors as volitional -- that is, narcissism is termed a personality disorder, but it tends to be discussed as a character disorder. This distinction is important to prognosis and treatment possibilities. If NPD is caused by infantile damage and consequent developmental short-circuits, it probably represents an irremediable condition. On the other hand, if narcissism is a behavior pattern that's learned, then there is some hope, however tenuous, that it's a behavior pattern that can be unlearned. The clinical literature on NPD is highly theoretical, abstract, and general, with sparse case material, suggesting that clinical writers have little experience with narcissism in the flesh.

There are several reasons for this to be so:

-- The incidence of NPD is estimated at 1% in the general population, though I haven't been able to discover the basis of this estimate.

-- Narcissists rarely enter treatment and, once in treatment, progress very slowly. We're talking about two or more years of frequent sessions before the narcissist can acknowledge even that the therapist is sometimes helpful. It's difficult to keep narcissists in treatment long enough for improvement to be made -- and few people, narcissists or not, have the motivation or the money to pursue treatment that produces so little so late.

-- Because of the influence of third-party payers (insurance companies), there has been a strong trend towards short-term therapy that concentrates on ameliorating acute troubles, such as depression, rather than delving into underlying chronic problems. Narcissists are very reluctant to open up and trust, so it's possible that their NPD is not even recognized by therapists in short-term treatment. Purely anecdotal evidence from correspondents and from observations of people I know indicates that selective serotonin-reuptake inhibitors, such as Prozac, aggravate narcissists' grandiosity and lack of social inhibition. It has also been suggested that self-help literature about bolstering self-esteem and getting what you want out of life or that encourages the feeling of victimization has aggravating effects on NPD thinking and behavior.

-- Most clinical writers seem unaware that narcissists' self-reports are unreliable. This is troubling, considering that lying is the most common complaint about narcissists and that, in many instances, defects of empathy lead narcissists to wildly inaccurate misinterpretations of other people's speech and actions, so that they may believe that they are liked and respected despite a history of callous and exploitative personal interactions.

[from Diagnostic and Statistical Manual of Mental Disorders, 4th edition, 1994, commonly referred to as DSM-IV, of the American Psychiatric Association. European countries use the diagnostic criteria of the World Health Organization.]

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy.[jma: NPD first appeared in DSM-III in 1980; before that time there had been no formal diagnostic description. Additionally, there is considerable overlap between personality disorders and clinicians tend to diagnose mixes of two or more. Grandiosity is a special case, but lack of empathy and exploitative interpersonal relations are not unique to NPD, nor is the need to be seen as special or unique.

The differential diagnosis of NPD is made on the absence of specific gross behaviors. Borderline Personality Disorder has several conspicuous similarities to NPD, but BPD is characterized by self-injury and threatened or attempted suicide, whereas narcissists are rarely self-harming in this way. BPD may include psychotic breaks, and these are uncharacteristic of NPD but not unknown. The need for constant attention is also found in Histrionic Personality Disorder, but HPD and BPD are both strongly oriented towards relationships, whereas NPD is characterized by aloofness and avoidance of intimacy. Grandiosity is unique to NPD among personality disorders, but it is found in other psychiatric illnesses. Psychopaths display pathological narcissism, including grandiosity, but psychopathy is differentiated from NPD by psychopaths' willingness to use physical violence to get what they want, whereas narcissists rarely commit crimes; the narcissists I've known personally are, in fact, averse to physical contact with others, though they will occasionally strike out in an impulse of rage.

It has been found that court-ordered psychotherapy for psychopaths actually increases their recidivism rate; apparently treatment teaches psychopaths new ways to exploit other people. Bipolar illness also contains strong elements of grandiosity. See more on grandiosity and empathy and its lack below.]The disorder begins by early adulthood and is indicated by at least five of the following:

Translation: Narcissistic Personality Disorder (NPD) is a pattern of self-centered or egotistical behavior that shows up in thinking and behavior in a lot of different situations and activities.

People with NPD won't (or can't) change their behavior even when it causes problems at work or when other people complain about the way they act, or when their behavior causes a lot of emotional distress to others (or themselves? none of my narcissists ever admit to being distressed by their own behavior -- they always blame other people for any problems). This pattern of self-centered or egotistical behavior is not caused by current drug or alcohol use, head injury, acute psychotic episodes, or any other illness, but has been going on steadily at least since adolescence or early adulthood.

NPD interferes with people's functioning in their occupations and in their relationships:
Mild impairment when self-centered or egotistical behavior results in occasional minor problems, but the person is generally doing pretty well.

Moderate impairment when self-centered or egotistical behavior results in: (a) missing days from work, household duties, or school, (b) significant performance problems as a wage-earner, homemaker, or student, (c) frequently avoiding or alienating friends, (d) significant risk of harming self or others (frequent suicidal preoccupation; often neglecting family, or frequently abusing others or committing criminal acts).

Severe impairment when self-centered or egotistical behavior results in: (a) staying in bed all day, (b) totally alienating all friends and family, (c) severe risk of harming self or others (failing to maintain personal hygiene; persistent danger of suicide, abuse, or crime).

1. An exaggerated sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)
Translation: Grandiosity is the hallmark of narcissism. So what is grandiose?

The simplest everyday way that narcissists show their exaggerated sense of self-importance is by talking about family, work, life in general as if there is nobody else in the picture. Whatever they may be doing, in their own view, they are the star, and they give the impression that they are bearing heroic responsibility for their family or department or company, that they have to take care of everything because their spouses or co-workers are undependable, uncooperative, or otherwise unfit. They ignore or denigrate the abilities and contributions of others and complain that they receive no help at all; they may inspire your sympathy or admiration for their stoicism in the face of hardship or unstinting self-sacrifice for the good of (undeserving) others. But this everyday grandiosity is an aspect of narcissism that you may never catch on to unless you visit the narcissist's home or workplace and see for yourself that others are involved and are pulling their share of the load and, more often than not, are also pulling the narcissist's share as well. An example is the older woman who told me with a sigh that she knew she hadn't been a perfect mother but she just never had any help at all -- and she said this despite knowing that I knew that she had worn out and discarded two devoted husbands and had lived in her parents' pocket (and pocketbook) as long as they lived, quickly blowing her substantial inheritance on flaky business schemes. Another example is claiming unusual benefits or spectacular results from ordinary effort and investment, giving the impression that somehow the narcissist's time and money are worth more than other people's. [Here is an article about recognizing and coping with narcissism in the workplace; it is rather heavy on management jargon and psychobabble, but worth reading. "The Impact of Narcissism on Leadership and Sustainability" by Bruce Gregory, Ph.D. "When the narcissistic defense is operating in an interpersonal or group setting, the grandiose part does not show its face in public. In public it presents a front of patience, congeniality, and confident reasonableness."]

In popular usage, the terms narcissism, narcissist, and narcissistic denote absurd vanity and are applied to people whose ambitions and aspirations are much grander than their evident talents. Sometimes these terms are applied to people who are simply full of themselves -- even when their real achievements are spectacular. Outstanding performers are not always modest, but they aren't grandiose if their self-assessments are realistic; e.g., Muhammad Ali, then Cassius Clay, was notorious for boasting "I am the greatest!" and also pointing out that he was the prettiest, but he was the greatest and the prettiest for a number of years, so his self-assessments weren't grandiose. Some narcissists are flamboyantly boastful and self-aggrandizing, but many are inconspicuous in public, saving their conceit and autocratic opinions for their nearest and dearest. Common conspicuous grandiose behaviors include expecting special treatment or admiration on the basis of claiming (a) to know important, powerful or famous people or (b) to be extraordinarily intelligent or talented. As a real-life example, I used to have a neighbor who told his wife that he was the youngest person since Sir Isaac Newton to take a doctorate at Oxford. The neighbor gave no evidence of a world-class education, so I looked up Newton and found out that Newton had completed his baccalaureate at the age of twenty-two (like most people) and spent his entire academic career at Cambridge. The grandiose claims of narcissists are superficially plausible fabrications, readily punctured by a little critical consideration. The test is performance: do they deliver the goods? (There's also the special situation of a genius who's also strongly narcissistic, as perhaps Frank Lloyd Wright. Just remind yourself that the odds are that you'll meet at least 1000 narcissists for every genius you come across.) [More on grandiosity.]

2. Preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love
Translation: Narcissists cultivate solipsistic or "autistic" fantasies, which is to say that they live in their own little worlds (and react with affront when reality dares to intrude).

3. Believes he is "special" and can only be understood by, or should associate with, other special or high-status people (or institutions)
Translation: Narcissists think that everyone who is not special and superior is worthless. By definition, normal, ordinary, and average aren't special and superior, and so, to narcissists, they are worthless.

4. Requires excessive admiration
Translation: Excessive in two ways: they want praise, compliments, deference, and expressions of envy all the time, and they want to be told that everything they do is better than what others can do. Sincerity is not an issue here; all that matter are frequency and volume.

5. Has a sense of entitlement
Translation: They expect automatic compliance with their wishes or especially favorable treatment, such as thinking that they should always be able to go first and that other people should stop whatever they're doing to do what the narcissists want, and may react with hurt or rage when these expectations are frustrated.

6. Selfishly takes advantage of others to achieve his own ends
Translation: Narcissists use other people to get what they want without caring about the cost to the other people.

7. Lacks empathy
Translation: They are unwilling to recognize or sympathize with other people's feelings and needs. They "tune out" when other people want to talk about their own problems.

In clinical terms, empathy is the ability to recognize and interpret other people's emotions. Lack of empathy may take two different directions: (a) accurate interpretation of others' emotions with no concern for others' distress, which is characteristic of psychopaths; and (b) the inability to recognize and accurately interpret other people's emotions, which is the NPD style. This second form of defective empathy may (rarely) go so far as alexithymia, or no words for emotions, and is found with psychosomatic illnesses, i.e., medical conditions in which emotion is experienced somatically rather than psychically. People with personality disorders don't have the normal body-ego identification and regard their bodies only instrumentally, i.e., as tools to use to get what they want, or, in bad states, as torture chambers that inflict on them meaningless suffering. Self-described narcissists who've written to me say that they are aware that their feelings are different from other people's, mostly that they feel less, both in strength and variety (and which the narcissists interpret as evidence of their own superiority); some narcissists report "numbness" and the inability to perceive meaning in other people's emotions.

8. Is often envious of others or believes that others are envious of him

Translation: No translation needed.

9. Shows arrogant, haughty, patronizing, or contemptuous behaviors or attitudes

Translation: They treat other people like dirt.


Avoidant personality disorder (APD or AvPD) or Anxious personality disorder (APD):
social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation and avoidance of social interaction

is a personality disorder from the DSM handbook, characterized by a pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation and avoidance of social interaction. People with avoidant personality disorder often consider themselves to be socially inept or personally unappealing, and avoid social interaction for fear of being ridiculed, humiliated, rejected or disliked. They typically present themselves as loners and report feeling a sense of alienation from society.

Avoidant personality disorder is usually first noticed in early adulthood, and is associated with perceived or actual rejection by parents or peers during childhood. Whether the feeling of rejection is due to the extreme interpersonal monitoring attributed to people with the disorder is still disputed.

Manifestation Of APD

The usual onset for APD ís early adulthood, with an equal prevalence rate among women & men (APA). According to one study however, (Greenberg & Stravynski, 1985) most of the people being referred for professional help for social dysfunction, considered to be the same disorder as APD by Marks (1987), were single men. One suggested hypothesis for this finding ís that society expects men to be the initiators ín romantic relationships. Therefore, when they do not form relationships, ít ís seen as more of a problem than women who do not initiate relationships but are not expected to ín any case (Marks). Millon & Everly have suggested 6 dimensions onto which the symptoms of APD can be mapped.

1.  Behavioral Appearance
Avoidants do exhibit the stereotypical traits of shyness, timidity & withdrawing behavior although sometimes they appear as aloof. To those who know them well, the avoidants’ mistrust of others may also be apparent as an almost constant wariness. However, Kantor (1993) argues that behavioral hostility ís also typical of those suffering with APD. Avoidants may use their shyness as a way to hurt others by preventing them from becoming close. Alternatively, they will demonstrate their hostility ín a more overt manner by insulting people who attempt to be friendly, for example. This reaction may be because they are identifying their aggressor & “deal with feared rejection by becoming rejecting themselves.” These expressions of hostility could be seen as defensive fight responses. To protect themselves from being rejected, they reject others first. This ís maladaptive because the avoidants will tend to reject many people who would never have rejected them ín the first place.

In terms of appearance, íf ít ís affected at all by APD, ít will tend to be affected ín one of 3 ways. 1st, avoidants may put considerable time & effort into making themselves attractive to others. The idea behind this ís, at least they will be liked for their looks, íf not for themselves. 2nd, they may consciously, or unconsciously, ensure that their appearance drives others away. This provides them with some control over their lives. Rather than waiting helplessly to be rejected, they ensure rejection from the start by their own actions. 3rd, ín the case of avoidants who are suffering from PTSD, for example, they may dress ín the style of the era when the trauma occurred. This form of dress ís an indication that they are living ín the past.

Speech ís may also be affected ín APD. Avoidants may be quite silent. As Jerome Kagan explains, “For a rabbit, freezing on a lawn ís a sign of fear. I believe that speechlessness ís a similar diagnostic sign for us… There’s a circuit ín the brain that controls our vocal cords & becoming quiet can be one sign of fear.” (Galvin, 1992). When they do speak, avoidants may use frequent pauses & speak slowly (Millon & Everly). This ís contrary to what we read regarding social phobia, where pauses ín speech tended to be avoided because they were thought to be a sign of lack of knowledge. Avoidants may also be overtalkative, possibly due to an adrenic discharge or a false belief, such as continuously talking will prevent death. For avoidants who try to put people off with their behavior, insults or social faux pas are commonly used as a way to assure rejection (Kantor). While this does essentially realize their worst fear, ít does again give avoidants some control over how others react to them.
2.  Interpersonal Conduct
Avoidants often test others to determine whether or not they are being sincere ín their friendliness. Because they may frequently see rejection where ít does not exist, people will tend to fail these tests & then later be avoided because they may reject or humiliate those with APD (Millon & Everly). They will, therefore, frequently have difficulty beginning & maintaining relationships (Kantor), partly because they have difficulty trusting others & thus, are very reluctant to share their feelings or allow themselves to be vulnerable. As a protective measure against the humiliation & rejection, they may become avoidant of others and are prone to 'compulsive self-reliance' since they are most comfortable when depending solely on themselves. The perceived obligations of being in emotional debt are untenable.

On the other hand, avoidants may form relationships, even making an effort to meet new people. However, these people are kept at a distance. Therefore, this group of avoidants ís avoiding intimacy, rather than avoiding people altogether.
3.  Cognitive Style
Avoidants excessively monitor the situation to the extent that they are trying to process so much information, they are no longer paying sufficient attention to the interaction itself (Millon & Everly). The literature on social phobia suggests that the phobics are unable to follow the interaction because they are so focussed on their internal reactions. However, the research on avoidant personality disorder also emphasizes that the avoidants are engaged ín external monitoring of the other person’s reactions as well. This additional processing of information could contribute to the increased severity of APD over social phobia. The excessive monitoring by avoidants, combined with a hypersensitivity to rejection makes their perception of rejection almost inevitable.

Their dysfunctional thought processes may also include fear of being vulnerable, because ít makes ít easier to get hurt or humiliated. They may also be perfectionists & reject anyone who does not live up to their impossible standards. This may again be a case of rejecting someone before they are rejected themselves. Another possibility ís that they are degrading the other person so that íf they are rejected they will find ít less painful because they didn’t like the person anyway. Some people believe that relationships are just too much work & aren’t worth the effort. Rationalization may also be present ín this belief with the idea that ít ís not because they are unable to form relationships that they don’t have any, ít ís that they do not want to waste their time on relationships. Some avoidants even believe that they must avoid intimacy because “giving love to others reduces the energy they have available for themselves & that they need for their vital life processes,” (Kantor).
4.  Affective Expression
People with APD may exhibit little affect due to the fear that showing their emotions will make them vulnerable to rejection or humiliation (Kantor; Millon & Everly). To observers, avoidants may appear tense & anxious (Millon & Everly). 

5.  Self-perception
Avoidants tend to have low self-esteem & believe that they are unworthy of being ín successful relationships. They are also very self-conscious, frequently lonely & see their accomplishments as being of little or no worth (Millon & Everly).

6.  Primary Defense Mechanism
To cope with their unhappiness, people with APD often escape into fantasy which ís “a ‘safe’ medium ín which to discharge affection, aggression or other impulses that would otherwise be inappropriate, uncomfortable or impossible to achieve ín reality,” (Millon & Everly). Avoidants will tend to read, watch TV, use a computer or daydream to escape from reality. 

Individuals with AvPD are preoccupied by the unpleasant and perplexing personal definition they hold of themselves as defective, unable to fit in with others, being unlikable, and being inadequate. This self-image usually results from childhood rejection by significant others such as parents, siblings, or peers. These individuals then believe that others throughout their lives will react to them in a similar fashion. They are often unable to recognize their own admirable qualities that make them both likable and desirable (Will, Retzlaff, ed., 1995, p. 97). Rather, they see themselves as socially inept and inferior. They believe that they are personally unappealing and interpersonally inadequate. They describe themselves as ill at ease, anxious, and sad. They are lonely; they feel unwanted and isolated. Individuals with AvPD are introspective and self-conscious. They usually refer to themselves with contempt (Millon & Davis, 1996, p. 263).

For individuals with AvPD, their deflated self-image references their entire being. Nothing about them escapes their own self-derision (Millon & Davis, 1996, p. 264). Doubts about their social competence and personal appeal become especially severe in the presence of strangers (DSM-IV, 1994, p. 662).

View of Others
Individuals with AvPD view the world as unfriendly, cold, and humiliating (Millon & Davis, 1996, p, 265). People are seen as potentially critical, uninterested, and demeaning (Beck, 1990, pp. 43-44); they will probably cause shame and embarrassment for individuals with AvPD. As a result, people with AvPD experience social pananxiety and are awkward and uncomfortable with people (Millon & Davis, 1996, p. 261). However, they are caught in an intense approach-avoidance conflict; they believe that close relationships would be rewarding but are so anxious around people that their only solace or comfort comes in avoiding most interpersonal contact (Donat, Retzlaff, ed., 1995, p. 49).

Individuals with AvPD tend to respond to low-level criticism with intense hurt. To make matters worse, they become so socially apprehensive that neutral events may well be interpreted as evidence of disdain or ridicule by others (Donat, Retzlaff, ed., 1995, p. 49). They come to expect that attention from others will be degrading or rejecting. They assume that no matter what they say or do, others will find fault with them (DSM-IV, 1994, p. 662).

Even memories for individuals with AvPD are comprised of intense, conflict-ridden, problematic early relationships. They must avoid the wounds inside of them at the same time they are avoiding the external distress of contact with others. The external environment brings no peace and comfort and their painful thoughts do not allow them to find solace within themselves (Millon & Davis, 1996, pp. 263-264).

Individuals with AvPD are "lonely loners." They would like to be involved in relationships but cannot tolerate the feelings they get around other people. They feel unacceptable, incapable of being loved, and unable to change. Because they retreat from others in anticipation of rejection, they lead socially impoverished lives. They have immature and unrealistic expectations of relationships; they believe that they can have no imperfections if they are to be accepted and loved. Interpersonally, they are ill at ease, awkward and tense. They experience unremitting self-consciousness, self-contempt and anger toward others (Oldham, 1990, pp. 188-193).

Individuals with AvPD will develop intimacy with people who are experienced as safe. Nevertheless, they will often engage in triangular marital or quasi-marital relationships which provide intimacy while maintaining interpersonal distance. These individuals like to foster secret liaisons as a "fall-back" position in case the key relationship does not work out (Benjamin, 1983, pp. 307-308). As sexual partners and parents, people with AvPD appear self-involved and uncaring (Kantor, 1992, p. 109) as they preserve distance from others through defensive restraint and withdrawal. Even so, these individuals long for affection and fantasize about idealized relationships (DSM-IV, 1994, p. 663).

AvPD Behavior
Individuals with AvPD behave in a fretful, restive manner. They overreact to innocuous experiences but maintain control over their physical behaviors and expression of emotions. Their speech is hesitant and constrained. They appear to have fragmented thought sequences and their conversation is laced with confused digressions. They are timid and uneasy (Millon & Davis, 1996, p. 261).

Kantor (1992, pp. 36-41) notes that individuals with AvPD, as with all of the personality disorders, have a tendency to live in the past or in fantasy -- they receive too little input from the here and now. This diminished ability to pay attention results in mild memory disturbances and a characteristic immaturity. These individuals are distracted by their own extraordinary sensitivity to subtleties of tone and feeling; they are hyperalert to the meaning of emotive communication. Their thought processes are interfered with by flooding of irrelevant environmental details (Millon & Davis, 1996, p. 263).

Individuals with AvPD behave in a stiff, shy, and apprehensive manner that is disquieting to others. The very rejection they fear may be the direct result of other people becoming impatient and uncomfortable with their unremitting tension and inability to accept that they can be a part of interaction without special guarantees of safety. In fact, people with AvPD, overtly or covertly, are seeking others to take the interpersonal risks for them; they are not able to be responsible for their own well-being socially and become a burden on the nurturing and care-taking capacity of those around them. For those who experience severe avoidant symptoms, no amount of protectiveness or gentleness can ease their fear; they will withdraw without explanation and leave behind a general bewilderment about what went wrong.

Avoidants often report having a poor memory particularly for peoples names.
An emerging literature has begun to document the cognitive consequences of emotion regulation. A process model of emotion suggests that expressive suppression (conscious efforts to inhibit overt emotion-expressive behavior), should reduce memory for emotional events. Results from recent studies have supported this.

Since people with APD are consistantly tense & anxious and exposed to emotion-eliciting situations but may exhibit little affect due to the fear that showing their emotions will make them vulnerable to rejection or humiliation (Kantor; Millon & Everly), it is likely that emotion-expressive suppression is an almost constant feature.
The literature on social phobia suggests that the phobics are unable to socialy interact because they are so focussed on their internal reactions. Research on avoidant personality disorder also emphasizes that avoidants are engaged in external monitoring of the other person’s reactions as well.

The excessive monitoring by avoidants together with rigorous expressive suppression may use up a large portion of finite psychological resources resulting in a decrease of memory for the details of the unfolding emotion-eliciting situation.

Avoidant Personality Disorder does not generaly impact on an individuals intellectual or physical capacities. In 'safe' familiar situations they will generally demonstrate no symptoms.

Job seeking can be very challenging because it triggers the individuals basic concerns. The individual will often have a great deal of difficulty effectively presenting their skills and qualifications. They will be awkward and uncomfortable in a job interview. An employer could easily discount the individuals abilities because of the manner in which they present themselves.

In employment they may have a great deal of trouble in new or changing situations. They will have trouble with interpersonal relationships and public speaking. They will tend to be perfectionists but downplay their skills, abilities and accomplishments. They will have a great deal of difficulty with any job that requires them to "sell" or even present their work to a potential customer, or even other co-workers.

Since their standard practice is to avoid situations that elicit their anxiety, they may just not attend important meetings, or be unable to participate in team discussions because they cannot allow themselves to feel part of a team.


Dependent personality disorder (DPD),
pervasive psychological dependence on other people.

formerly known as asthenic personality disorder, is a personality disorder that is characterized by a pervasive psychological dependence on other people. The difference between a 'dependent personality' and a 'dependent personality disorder' is somewhat subjective, which makes a diagnosis sensitive to cultural influences such as gender role expectations.

Clinical interest in dependent personality disorder has existed since Karl Abraham first described the oral character. As a disorder, the personality type first appeared in a War Department technical bulletin in 1945 and later in the first edition of the Diagnostic and Statistical Manual in 1952 (American Psychiatric Association, 1952) as a subtype of passive-aggressive personality disorder. Since then, a surprising number of studies have upheld the descriptive validity of dependent personality traits, viewed as submissiveness, oral character traits, oral dependence, or passive dependence, or as a constellation of both pathological and adaptive traits under the rubric dependency.

Diagnostic criteria (DSM-IV-TR)
The DSM-IV-TR, a widely used manual for diagnosing mental disorders, defines dependent personality disorder as a "pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

•  Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others
•  Needs others to assume responsibility for most major areas of his or her life
•  Has difficulty expressing disagreement with others because of fear of loss of support or approval (this does not include realistic fears of retribution)
•  Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy)
•  Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant
•  Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself
•  Urgently seeks another relationship as a source of care and support when a close relationship ends
•  Is unrealistically preoccupied with fears of being left to take care of himself or herself
•  Many cases of dependent also have roots to Obsessive-compulsive disorder, and instead of being afraid if they are alone when not in a relationship, tend to think everything is wrong.

A mnemonic that can be used to remember the criteria for dependent personality disorder is DEPENDENT.

D – Difficulty making everyday decisions.
E – Excessive lengths to obtain nurturance and support from others
P – Preoccupied with fears of being left to take care of self
E – Exaggerated fears of being unable to care for himself or herself
N – Needs others to assume responsibility for his or her life
D – Difficulty expressing disagreement with others
E – End of a close relationship is the beginning of another relationship
N – Noticeable difficulties in initiating projects or doing things on his or her own
T – “Take care of me” is his or her motto

Treatment Techniques
Treatment Techniques (Zimmerman, 1994, pp. 118-119) suggests the following questions when assessing individuals for DPD:
Some people enjoy making decisions. Others prefer to have someone they trust guide them. Which do you prefer?
Do you seek advice for everyday decisions?
Do you find yourself in situations where other people have made decisions about important areas in your life, e.g. what job to take?
Is it hard for you to express a different opinion with someone you are close to? What do you think might happen if you did?
Do you often pretend to agree with others even if you do not? Why?
Do you often need help to get started on a project?
Do you ever volunteer to do unpleasant things for others so they will take care of you when you need it?
Are you uncomfortable when you are alone? Are you afraid you will not be able to take care of yourself?
Have you found that you are desperate to get into another relationship right away when a close relationship ends? Even if the new relationship might not be the best person for you?
Do you worry about important people in your life leaving you?

Treatment Goals
Adler (Adler, ed., 1990, pp. 26-28) suggests that treatment goals for all personality disorders include: preventing further deterioration, regaining an adaptive equilibrium, alleviating symptoms, restoring lost skills, and fostering improved adaptive capacity. Goals may not necessarily include characterological restructuring. The focus of treatment is adaptation, i.e., how individuals respond to the environment. Treatment interventions teach more adaptive methods of managing distress, improving interpersonal effectiveness, and building skills for affective regulation. For individuals with DPD, the goal of treatment is not independence but autonomy. Autonomy has been defined as the capacity for independence and the ability to develop intimate relationships (Beck & Freeman, 1990, p. 291).

Sperry (1995, p. 86 - 91) suggests that the basic goal for DPD treatment is self-efficacy. Individuals with DPD must recognize their dependent patterns and the high price they pay to maintain those patterns. This allows them to explore alternatives. The long-range goal is to increase DPD individuals' sense of independence and ability to function. Clients with DPD must build strength rather than foster neediness (Benjamin, 1993, p. 238). As with other personality disorders, treatment goals should not be in contradiction to the basic personality and temperament of these individuals. They can work toward a more functional version of those characteristics that are intrinsic to their style. Oldham (1990, p. 104) suggests seven traits and behaviors of the "devoted personality style," i.e, the non-personality-disordered version of DPD:

•  ability to make commitments;
•  enjoyment of intimacy;
•  skills as a team player -- without need to compete with the leader;
•  willingness to seek the opinions and advice of others;
•  ability to promote interpersonal harmony;
•  thoughtfulness and consideration for others; and,
•  willingness to self-correct in response to criticism.

Obsessive-compulsive personality disorder (OCPD), (not the same as Obsessive-compulsive disorder): characterized by rigid conformity to rules, moral codes, and excessive orderliness

or anankastic personality disorder, is a personality disorder that is characterized by a general psychological inflexibility, rigid conformity to rules and procedures, perfectionism, moral code, and/or excessive orderliness.

Obsessive compulsive personality disorder (OCPD) is often confused with obsessive-compulsive disorder (OCD). This could be due to the more commonly known OCD and the similarities in name of the two disorders, however the mindsets are typically different and unrelated.

Those who are experiencing OCPD do not generally feel the need to repeatedly perform ritualistic actions - a common symptom of OCD. Instead, people with OCPD tend to stress perfectionism above all else, and feel anxious when they perceive that things are not "right."

People with OCPD may try to rid themselves of excess energy when anxious or excited by twitching or doing unpredictable things. They may hoard money for future use, keep their home perfectly organized, or be anxious about delegating tasks for fear that they won't be completed correctly. There are four primary areas that cause anxiety for OCPD personalities: time, relationship, uncleanliness, and money. There are few moral 'grey' areas for a person with fully developed OCPD; actions and beliefs are either completely right, or absolutely wrong. As might be expected, interpersonal relationships are difficult because of the excessive demands placed on friends, romantic partners and children. Persons with OCPD often have a negative outlook on life (pessimism).

Obsessive Compulsive Personality Disorder:
A Defect of Philosophy, not Anxiety

Steven Phillipson, Ph.D. Center for Cognitive-Behavioral Psychotherapy

Obsessive Compulsive Personality Disorder (OCPD) is a pervasive characterological disturbance involving one's generalized style and beliefs in the way one relates to themselves and the world. Persons with OCPD are typically deeply entrenched in their dysfunctional beliefs and genuinely see their way of functioning as the "correct" way. Their overall style of relating to the world around them is processed through their own strict standards. While generally their daily experience is such that "all is not well," they tend to be deeply committed to their own beliefs and patterns. The depth of ones belief that "my way is the correct way" makes them resistant to accepting the premise that it is in their best interest to let go of "truth owning." Yet letting go of truth is paramount in their recovery. For the purposes of this article "truth" is defined as a person's rigidly held belief which s/he feels is universally applicable. Most often, blame for ones internal strife, is placed on external circumstances or the environment.

OCPD and Obsessive Compulsive Disorder (OCD) are often confused as they are thought of as being similar. There is, however, a great difference between the two conditions. Persons with OCD experience tremendous anxiety related to specific preoccupations, which are perceived as threatening. Within the condition of OCPD it is one's dysfunctional philosophy which produces anxiety, anguish and frustration. It has been well established that OCD is a condition in which people perform elaborate rituals to avoid or escape anxiety. Repetitive rituals are performed to undo the threat. Their overall genuine nature tends not to be affected by the condition and in the vast majority of the cases they recognize that the concerns are irrational. A person with washing rituals due to fears about contracting aids from a public door knob might still be very willing to sky dive or go white water rafting. This suggests that a person's inclination toward risk taking is not affected by their anxiety about germs.

This paper will attempt to convey a personality style that has devastating effects on one's emotional wellbeing, work productivity and interpersonal relationships. Although there is a moderate overlap between OCPD and OCD in regard to similarity of rituals, the pervasive differences might justify a relabeling (such as perfectionistic personality disorder) of this condition. OCPD wreaks havoc within a person's life due to a dysfunctional perspective. The movie "As Good as It Gets" unfortunately portrays a muddled combination of these two conditions, although it was touted as the OCD movie. The main character engages in a variety of OCD rituals, yet his overall demeanor is that of an angry, belligerent, intolerant loner who clearly has an exaggerated form of OCPD as his main handicap.

For those who have OCD, reading this paper will be very provocative. Not only are some of the characteristics similar to the population at large but there is going to be an unsettling degree of similarity between OCD and OCPD. If you have OCD, please do not read this paper and attempt to diagnosis yourself. It is not in the surface similarities that the distinction is made between the two conditions. Instead the distinction lies within the underlying rationale of these key elements. It requires vast training and clinical experience to distinguish the subtle but drastic contrast between the two conditions. Making an accurate diagnosis is therefore best left up to a qualified specialist. The purpose of this paper is to qualify aspects of this condition so that those who see glaring similarities to themselves or significant others may be better informed and possibly seek treatment. OCPD is a pervasive condition involving ones life philosophy where the characteristics are vast and complicated. To qualify for a diagnosis of OCPD one need not possess all of the following manifestations nor is one or two similarities sufficient. A combination of the following dispositions in an extreme form is generally grounds for a diagnosis.

Generally two hallmark thinking styles are pervasive for persons who suffer this condition. The primary manifestations of OCPD entail either a bent toward perfectionistic standards or righteous indignation. Along with perfectionism comes relentless anxiety about not getting things perfect. Getting things correct and avoiding at all costs the possibilities of making an error is of paramount importance. This perspective produces procrastination and indecisiveness. The second factor entails the rigid ownership of truth. This feature produces anger and conflict. Persons with OCPD generally lean toward one of these perspectives or another. In some cases both perspectives are of equal magnitude. Rituals, on the other hand, often play a relatively small part in this complex syndrome of perfectionistic mannerisms, intense anger and strict standards. Their way is the correct way and all other options are "WRONG". Anger and contempt are rarely held at bay for those who disagree.

The Diagnostic and Statistical Manual of Mental Disorders (DSM III-R, the bible for persons in the mental health profession)suggests that persons with OCPD display a pervasive pattern of orderliness, perfectionism, and/or mental and interpersonal control, at the expense of flexibility, openness, and efficiency. It is further suggested that persons with this condition tend to resist the authority of others while simultaneously demanding that others conform to their way of doing things. The DSM III-R's pervasive focus relates to the person's inability to attain completion of tasks due to the inordinately high standards, which are placed on almost all aspects of living.

Clients tend not to enter therapy for the express purpose of being treated for OCPD. Typically a diagnosis will be made by the clinician after other topics have been explored. Why seek out the help of others when one possesses ultimate knowledge. Perhaps this trend will now change due to an increasing awareness of the manifestations of this condition. Three pervasive rationales for entering therapy have entailed: seeking treatment for OCD rituals, which are becoming burdensome; a generalized dysphoric experience thought to be related to depression or social isolation; and/or marital discord where they have received an ultimatum from their spouse to "get help or get out."

Associated Features
Associated features, according to the DSM III-R, often entail, distress related to a tremendous amount of indecisiveness, difficulty expressing tender feelings and a depressed mood. From my own clinical observations it seems that emotional and cognitive rigidity are the hallmark indices suggesting the existence of OCPD. When events stray from what a person's sense of how things "should be," bouts of intense anger and emotional discord are characteristic.

Indecisiveness: When almost all decisions seem to take on the same paramount importance and being correct is imperative, making even simple choices can become a nightmare. Persons with OCPD can become stymied in life due to an inability to establish with certainty which choice is the correct one. Not unusual would be for someone to spend over ten minutes attempting to choose the correct pair of socks which best matches their tie. They tend to place a great deal of pressure on themselves and on others to not make mistakes. Within OCPD the driving force is to avoid being wrong. In contrast, the underlying rational for someone with OCD would typically be to make the correct decision so that nothing superstitiously bad would happen. Since continuously making the correct choices in life, seems to be an impossible task for us humans, there is a regular source of discontent available for OCPD sufferers.

This indecisiveness can have devastating effects on academic, professional and interpersonal relationships. From early adolescence, through college, perfectionism can take an otherwise straight "A" student and bring him to the brink of failure due to incomplete assignments. Having to get the term paper exactly correct makes for an almost impossible task. An extremely difficult time making decisions (always looking for the correct choice) contributes to procrastination. Frequently even starting a task seems impossible, due to a need to sort out the priorities correctly. If it takes an hour to complete the first paragraph of a report, because revision after revision never seems to get it perfect, imagine the anguish experienced when contemplating the completion of a two thousand word essay. The time it could take to complete a ten page report might be multiplied by five due to checking or rewording so that it is just so.

Imagine a college student who has to choose a major and in doing so be convinced that she is completely correct in her choice. The expression of this, "need", to have a perfect academic fit is seen in some students having multiple majors during their four year stint. Changing colleges, due to emerging complications and disillusionment, is also a possible manifestation of OCPD.

The need for an occupational exact fit, can also bring long term investment in a career choice to a screaming halt. Many aspects of any career can seem very appealing in their conceptualization. Things can always look great from afar. As one becomes more thoroughly educated about any school, career or person, through experience, the pitfalls become more apparent. Since perfection is often sought, the emerging defects of any career choice often deter a prolonged investment in any specific area of focus. Making a definitive choice and changing jobs can become stymied due to the endless pursuit of figuring out which of the available options is best.

Aspirations for perfection can play themselves out in interpersonal relationships as well. Since all humans carry a significant amount of emotional baggage it typically doesn't take long in a dating or marital situation to discover our partners' flaws. For someone with OCPD choosing a partner who lives up to their unreasonably high standards is very difficult, if not impossible. Remaining invested in a relationship without bouts of volatility over the long haul is highly unlikely. For those who do remain in long term relationships chronic discord tends to be pervasive.

Emotional Rigidity: In a world where being in control is of paramount importance, dealing effectively with the volatility of emotions is extremely difficult. Since emotionality is associated with spontaneity and upheaval (i.e. loss of control), responding to emotions effectively and appropriately places an abundance of pressure on the OCPD to keep them constricted. Exerting effort to contain "out-bursts" of emotion is an everyday phenomenon. It seems however that there is one emotion which exists in abundance. The expression of anger tends to come out naturally and in excess. Anger, as an emotion, is one of the most basic and easily triggered of human reactions. Anger is only seconded by anxiety in its primitive nature. Vulnerability, (one of the most advanced of human emotions), as seen through the eyes of the OCPD sufferer, compels people to act in silly ways and expose themselves to the possibility of rejection. Emotional constraint is exerted to prevent the possibility that one may act in a regrettable way. The result of this emotional constraint is that all displays of emotion sometimes becomes compressed into an expression of flat affect. Anxiety and happiness can be perceived as the same on the receiving end. It is not uncommon for persons with OCPD to have their humor often mistaken for seriousness. Jokes or sarcasm (seen by the deliverer as obvious) are mistaken for insults and political incorrectness.

Depressed Mood: Although rarely observed by others, the experience of inner turmoil within this syndrome is immense. As much as others are often victimized by OCPD's oppressive and demanding style, the high standards often apply two fold within the OCPD sufferers' expectations directed toward themselves. It is not uncommon for a person with OCPD to feel deeply entrenched in the belief that they are a "Good Person." This belief can paradoxically often lead to feelings of depression and disappointment. The high standards which a "Good Person" is expected to live up to are often far beyond the capacity for any human being to consistently fulfill. A belief such as "I know that I'm a good person, but I hate myself for doing so many wrong things" is not uncommon. This self-hatred along with tremendous disappointment can easily lead to feeling of depression. Since ones humanness prevents an OCPD sufferer from living according his own high standards, a tremendous amount of self-hatred is imposed. Recent research has documented that as much as seventy percent of depression can be attributed to feelings of low self-esteem and inadequacy. In my work with helping persons manage the challenges of self-esteem I have found it much more difficult to have persons who are "Good" come to find acceptance in being "human" than helping those with low self-worth rise up to the possibilities of self-acceptance.

Another contributor to depression within the OCPD population is a cognitive style characterized by dichotomous thinking. Dichotomous thinking is the tendency to categorize all aspects of life into one of two perspectives -- "All good" or "All bad." The world is viewed predominantly through clearly defined black and white realms. All that is pure and wholesome is valued. It can take only one stain or blemish to have the person completely find justification in discarding anything which evidences a flaw. Within their own being these rigid standards can be devastating to one's self image. Fault finding in one's own world produces a regular source of conflict in maintaining the high standards of life.

Accompanying Rituals
Common rituals, which accompany the OCP syndrome typically, involve (1) perfectionism, (2) hoarding, and (3)ordering.

Perfectionism: Perfectionism as expressed by the OCPD is not the admirable quality often sought by the world at large. As a ritualistic aspect of this condition the OCP perfectionism entails checking and rechecking "completed" tasks to be absolutely sure that there are no imperfections. It could literally take upwards of 10 to 20 minutes to fill out a check or mail an envelope due to a rigid need to ensure that there are absolutely no mistakes. It is as if, to make a mistake which might be noticed would ruin ones reputation for life. Perfectionism could also take the form of a need for over completeness -- reading and rereading material until a sense of absolute clarity exists. Not only is it extremely time consuming but the overall content of the story is lost. The forest is missed while examining each leaf, of each branch, of each tree. This disposition can also have an adverse impact on one's conversational style. In the course of a conversation sometimes information is sought which involves such minutiae that the questioned person becomes lost and frustrated. Slight inconsistencies or mistakes, within another's conversation, are often perceived by the OCPD sufferer. These details, no matter how peripheral to the conversation, must be brought out into the open and clarity must be achieved.

In some cases the corporate environment rewards a person's perfectionism. It is not uncommon for persons with OCPD to reach high levels on the corporate masthead because their productivity was not sufficiently impaired while their high standards seemed to reflect the company's dedication for quality. How often do we find subordinates complaining about the tyrant at the top? But more on this subject latter. Occasionally the OCPD sufferer may acknowledge that other ideas are also functionally correct, but then go off and spend a great deal of time and effort at coming up with an even more correct idea. This effort may produce a modicum of improvement at the expense of efficiency and productivity.

Hoarding: Hoarding involves the excessive saving or collecting of items (typically thought of as junk), such that it intrudes on the quality of life for the hoarder or those living with such a person. (Research at the Center for Cognitive-Behavioral Psychotherapy has begun to gain further insight into the relationship between hoarding and OCPD.) In a significant percentage of cases, people lack the insight that they are behaving in an unhealthy manner. When persons are not cognizant of the irrational nature of this condition it is referred to as overvalued ideation (ego-syntonic OCD). Typically this form of OCD involves a poor prognosis since the individual is rarely willing to confront the challenges offered by the treatment. This lack of willingness to see one's own culpability has a very adverse impact on the quality of life for those around her. Many hoarders, however, are well aware of the adverse impact of this condition and suffer tremendously as a consequence of seeing all free space within their living environment occupied. Renting extra storage space to pick up the overflow of ones own living environment is not uncommon.

Where hoarding is a component of OCPD, the justification for saving items typically involves one of the following rationales. In many instances there is a deep commitment related to the "sinfulness of waste." A father may say to his wife, "Why throw out the diapers when they're still in perfectly good shape," referring of course to their 15 year old daughter's leftover diapers. "Who knows? Maybe when she's a new parent the baby will be able to use these diapers." Another perspective which supports the hoarder's resistance to throwing out items is the possibility that the item may come in handy at some point in the future. Throwing away four year old TV guides would cause a tremendous upheaval since Mom may want to see which program was on NBC 9:00 pm Thursday 1994. Another determinant for hoarding involves the endless projects on the "to do list." Perfectionism often stymies the OCPD's ability to complete tasks. Rather than abandoning projects, they become piled up and the fantasy is maintained that some day they will be gotten to.

Ordering: A telltale sign of OCPD is ordering gone haywire. It would not be unusual for a person's cabinets or refrigerator to have the items placed in exactly their proper spot. The closet or drawers would tend to be aligned exactly as they "should be" while shirts and shoes pointed in the same direction. A client who had this manifestation of OCDP once mentioned that his wife often played the following game. She would go in the bedroom alone and move his shoelace an inch or adjust the angle of the phone an eight of an inch. When she would finally call him in, it would literally take him only 10 seconds to locate every item she had slightly adjusted.

For persons who are impaired by the ritual of ordering, there tends to be an overwhelming need to be in control of one's environment. If the items on one's desk are not put away exactly in their proper spot the world might be a much more threatening place. Imagine the unpredictable and threatening nature of the universe if things tended to not be just where they were left. With ordering as a manifestation of OCD and OCPD it is not uncommon to find a person placing and replacing items over and over again until they feel they have gotten it exactly right. Ordering also entails the placement of items in geometric symmetry. Parallel lines and even spacing seem to be of paramount importance. A client used to euphemistically refer to his stacks of items as "anal piles," amusingly recognizing his own need for obsessive structure. Symmetry can also be sought after in an obsessive way. Having to keep the world perfectly balanced can lead to rituals where items would need to be perfectly and evenly spaced. Touching both sides of an object or ones right and then left leg are also other examples of symmetry.

Owning Truth
We all periodically have such confidence in what we are saying that statements such as "I'm sure of it" or "The fact of the matter is..." play a natural part of our everyday vocabulary. For persons with OCPD, facts and confidence are all too often turned into "I'm RIGHT and your WRONG." "The way I see it represents the way it is, end of story". For others, refusing to yield to the "correct perspective" often entails encountering tension and discord. This manifestation of OCPD entails one's adamantly guarding his dogmatic beliefs to such a degree that casual conversation often converts minor disagreements into heated debates. The relative importance of any topic (i.e. comparing the effects of regular gas vs. high test on a particular car's performance) rarely is of consequence in determining the degree of the intensity expressed in the midst of the debate.

Perhaps there are a few variables on this planet, which are beyond debate in their apparent universal truthfulness. "Humans are a living organism when there is a heart beat and/or brain activity" or "Rocks eventually tend to drop in a downward direction when released into the air." For the person who experiences OCPD, abstract ideals and moral standards become rigidly held truths. An example belief would be that "The Mormon's practice of marrying more than one woman is illegal and absolutely wrong." The ideology that all-religious practices are subject to interpretation and not a matter of right or wrong is often overlooked and rarely considered. It is not unheard of for someone with OCPD to feel that he is flexible due to an occasional shift in his beliefs. If one listens carefully, the shift in position can be dramatic and equally dramatic is the degree to which the new truth is held as fact. The knowledge that abortion is "murder" can be converted to the fact that the freedom to chose represents every woman's "God Given" right to make decisions about her own body. Most examples of this particular cognitive shift would tend to go in the opposite direction.

It would not be unusual for an OCPD sufferer to literally take delight in being wronged, since it affords them, what they perceive, as the justified opportunity to deliver a steep punishment. The term "righteous indignation" was probably conceived with this perspective in mind. Crossing a person with OCPD provides her the license to hold a grudge and forever hold your mistake over your head.

In a conflict with someone who has OCPD, the non-OCPD person might be motivated to desperately seek closure. In the process of attempting conflict resolution, the non-OCPD might discover that every minute the quagmire becomes deeper and deeper. It is almost as if the mere effort to find resolution is a punishable offense. In a close relationship, encountering this zone of contempt is bewildering and frightening. All one wants to do is to bring this controversy to an end, and then, you are punished for not being willing to deal with the issue at hand. Within this zone, the person with OCPD feels a great need to bring about absolute clarity for the issue to be resolved. Once again this need for the perfect resolution creates a seemingly never ending tweaking of the issues. Agreeing to disagree is rarely a reasonable solution and often not in the scope of the OCPD's world.

Interpersonal Relationships
For many who have close contact with an OCPD sufferer there can be a pervasive experience of being ill at ease, while in the company of someone with OCPD. Often, being with persons who evidence this diagnosis, feels like walking in a field of land mines. One never knows when your going to step on one and pay a heavy emotional price for crossing the rigid standards. This ever present threat creates a tremendous amount of trepidation, resentment, and tension. These land mines can present themselves in association with seemingly random topics.

Within marital or familial relationships the divisiveness of this condition is most felt. Since ideology and correctness is placed before love and loyalty, divisiveness can break familial ties. Spouses can be subjected to daily scrutiny and given repeated feedback in a non-loving or supportive manner. The standard bearer must run his or her house like a tight ship -- from the children being kept in line (seen but not heard) to the outside appearance of the house, well manicured and tidy. The expression, both physically and emotionally, of tender feelings for "loved ones" is often painfully absent. Corporal punishment is not unusual since the mentality of "spare the rod and spoil the child" is even endorsed in the Bible. Wreaking humiliation seems to be just punishment since it closely approximates the inner experience of the OCPD sufferer's reaction to being wronged. In 1985 I was working in a university outpatient clinic with a child who's academic performance had lapsed far behind his intellectual capacity. Near the end our successful treatment I brought in the father of my client. My objective was to see if I might transfer the positive changes, which had occurred in the course of treatment, to the home. Near the end of the session I asked the father whether he was proud of his son for bringing up his grades so dramatically. I'll never forget the father's response in front of this child. "There's nothing to celebrate, these are the grades he SHOULD have gotten all along!"

In interpersonal relationships we all tend to hope for a little leeway in being given feedback for mistakes that we make. Persons with OCPD tend not to find it within themselves to provide a nurturing environment where being human and fallible is expected. Instead they feel put upon by others' mistakes and take license in extracting a heavy toll for even an initial infraction -- "Person's should know better and mistakes are just not to be tolerated." Often others in the presence of an OCPD sufferer find themselves embroiled in heated conflict over issues which pertain to seemingly trivial topics. It is not uncommon to become convinced that the OCPD sufferer actually takes delight in the heated nature of conflict. For those familiar with the OCPD's style, bailing out of a conversation and avoiding future areas of debate, is a pervasive response pattern. Not surprisingly this style of interaction has devastating effects on the great majority of relationships persons with OCPD have. Fault finding is the tendency for OCPD's to chronically pick out the flaws in others, especially those close enough to them to mention it. "You always misuse the word affect in stead of saying effect!" "Your hair is always so messy; don't you have any self respect?" It seems as if through criticism the receiver of the feedback will be inspired to get their act together.

For the OCPD sufferer, it is not uncommon for him to seek out the company of a significant other where his partner's personal disposition is that of being passive and non-conflictual. For a long-term significant relationship to survive with this diagnosis, it is almost essential for the partner to have great depths of resilience or dependency. Many OCPD relationships involve a clear distinction between the domineering and controlling spouse and the passive-dependent spouse. Mail order brides have sometimes provided an outlet for otherwise frustrated men who have found it difficult to cope with the ever-evolving power structure of women within today's western society.

Isolation due to rigidly held high standards is also a common result of OCPD. When perfectionistic standards are applied toward a partner's minute bodily defects or quirky personal style, the devastation wreaked within intimacy is astounding. I have all too often worked with clients who have legitimized ending relationships due to such minutiae as a significant others bad breath, small shoe size, or eyebrow thickness. An article written in New York Magazine, a few years ago, portrayed a satirical conversation which went something like this: "She's a Ph.D., expert skier, loves children and animals, and encourages me to spend as much time out with the guys as possible... it's just a shame she speaks French with a southern dialect". When this aspect of OCPD is manifested there is typically a pattern of failed relationships. The sufferer tends to consistently withdraw from a relationship soon after the development of intimacy. The awareness of the defect in one's partner as time goes on becomes so magnified, that after a while, the slight flaw which was not even noticed initially, becomes the only feature which is seen.

Poor social skills are often a consequence of a life-long pattern of rigid thinking. Being motivated to attend to subtle cues within one's social environment is lost due to the overriding perspective that "my way is the right way." Taking liberty to disclose radical opinions or facts, which are of an extreme nature, in the presence of a novel relationship or non-intimate acquaintances is a common characteristic. Whereas in a novel social setting, decorum pressures persons to withhold extreme positions, the OCPD sufferer feels that a lack of genuineness is wrong and being totally open, no matter what the consequence, is the only option. "If others are offended by what I say, too bad for them."

In professional relationships, subordinates of many OCPD's are often intimidated and frequently berated. Staff may experience tremendous inhibition in speaking freely about topics where there is not absolute certainty regarding the correctness of the statements. This environment facilitates the stifling of creativity and risk taking. Often the chain of command from above reinforces or ignores this style, since it appears that the manager is just being vigilant and instilling the company's commitment to excellence.

Friendships (how ever long lasting they may be) are often tenuous at best. Persons with OCPD, at the more extreme end of the continuum, project an air of consternation and rigidity. The eventual breakdown of casual relationships comes as a consequence of chronic tension and failed expectations. The internal schema (style of viewing life circumstances) of the sufferer is incapable of learning from these repeated failures due to the dogged conviction that the other person was at fault, and therefore the termination of the relation was justified.

Strict Moral Standards
"Premarital sex is wrong and it means that persons are tainted if they have ever engaged in it." "Girls who wear make up are loose and promiscuous." "Men who allow their wives to work are inadequate providers."

Moral righteousness and preaching morality as a dogmatic necessity is not an uncommon expression of OCPD. The avoidance of discussing religion or politics is certainly wise in the presence of the OCPD sufferer. Both of these realms are steeped in the potential for the OCPD sufferer's truth to override consideration and respect. In 1986 I flew with a client to Boston to aid him in his fear of flying. While at the airport in Boston we walked past a booth representing some very conservative organization (Linden LaRouch I believe). Out of nowhere, my 6'4" male client reached over the booth and grabbed the innocent fellow by the collar. My client proceeded to yell about the toxic ideology that this booth represented. In that moment this client graduated from fear of flying and commenced with a long year of work related to helping him let go of truth and anger. One of our agreed upon goals was for him to become more available to his friends, who had expressed that they were afraid to discuss any topic which he disagreed with. Our successful outcome boiled down to my client's willingness to replace "truth" with expressing his opinion in terms of degrees of confidence.

Excessive religious observance as in, strict adherence to ritualistic aspects of daily or weekly routines, is a potential component of OCPD. If a child would ask for rationales for following through with certain age old traditions the OCPD parent may respond with "You just do it and never question the relevance". Often persons with this form of OCPD, believe in literal interpretations of the Bible or Koran. Adamantly endorsing the idea that the world was created some 5864 years ago, despite the existence of rocks carbon dated to over a million years ago, would not be unexpected. Using the Wrath of God as a means of modifying behavior is often an unfortunate component of OCPD. Of course, religious intolerance is not surprisingly a derivative of this style of thinking. Finding fault with different views or creating fractions within divergent religious sects is not uncommon. The existence of hundreds of subsets amongst the Baptists and the ever-fractionalizing Hasidic (ultra-orthodox Jewish) community is evidence of religious leaders owning their interpretation of the Bible too rigidly. One of my favorite recollections of a female OCPD in discussing her spirituality was her reassurance that her observance of Eastern philosophy was the "True Buddhist" expression. The paradoxical humor is that letting go of truth is a spiritual goal of Buddhism (as I understand it).

The treatment of OCPD is incredibly complex and lengthy. Therefore, any depth in relaying the specifics of this treatment go well beyond the scope of this paper. Generally speaking the focus of Cognitive-Behavioral treatment for OCPD entails helping these individuals develop a greater tolerance to the notion that the world is exclusively made up of gray, not the clearly defined black and white lines of rigidly held beliefs. As is the case with all treatments there is an utmost emphasis on developing rapport and trust within the therapeutic relationship. Educating the client about the diverse nature of this condition offers the sufferer the option to identify those aspects of OCPD which are most salient to their own lives. Having the client identify that these dispositions are a handicap at all is a monumental achievement. The treatment would most likely focus on breaking down and intervening on specific individual aspects within the spectrum of OCPD. A standard cognitive-behavioral intervention might deal with the hoarding (using exposure and response prevention methods), while social skills training and role-playing might help facilitate a more effective style in relationships. Assertiveness training would facilitate one's ability to make requests or provide feedback such that the receiver of the information not be alienated. Overriding all of the specific interventions would be a sensitivity to helping the sufferer relinquish their dogmatic belief system. Letting go of "truth owning" and relating to one's world without needing to be "right" is a tremendous ambition. The dividend it pays is incomprehensible.

As has been previously stated, the existence of OCPD has devastating effects on relationships. The therapeutic relationship is unfortunately not excluded. Therapists may well be advised to forewarn all persons with OCPD that at some point in the course of therapy the clinician will inadvertently behave in a manner which will violate the client's perfectionistic standards. Rather than responding by terminating the relationships, this juncture provides the client with an opportunity to learn how to manage the conflict. Playing out conflict resolution in the course of therapy can be a powerful therapeutic tool. Being real and available to the client is critical. Once rapport has been established, giving honest and immediate feedback about the dynamics within the therapeutic relationship is imperative. Keeping the channels of communication open so that at the point where the client most desires ending the relationship, becomes the point where effective communication can take place to strengthen the foundation of the partnership. In all honesty, approximately 50% of OCPD clients remain on board for the long haul. Rather than seeing the actual conflict within the therapeutic relationship as the unavoidable manifestation of why they came into therapy in the first place, many bail prematurely due to the overwhelming sense of outrage that the doctor has made a mistake.

This paper represents a radical departure from the style of most of my previous writings. I am aware that there is an emphasis on the aftermath within oneself and on others, rather than a primary focus on understanding and compassion. I strongly believe that through being informed about this condition's manifestations, people can better seek appropriate treatment. Living out the patterns of OCPD for oneself and for others around you is devastating. If you are at the end of your rope and these characteristics are relevant, I strongly suggest you seek new paths.

Dissocial personality disorder
 (Not to be confused with Dissociative identity disorder)

is one of several psychopathic personality disorders, each of which has different operational definitions and terminologies depending on the system of classification of mental disorders used. Psychopathy is a general construct that differs from the specific diagnoses of antisocial, psychopathic, dissocial, and sociopathic personality disorders, the various diagnostic classifications for psychopathy. Dissocial personality disorder is the diagnostic category established for psychopathy in the ICD-10 diagnostic criteria developed by the World Health Organization WHO). It is conceptually similar to the DSM-IV-TR diagnostic criteria for Antisocial personality disorder.

ICD-10 Criteria for Dissocial Personality Disorder
Specifically, the dissocial personality disorder is described by the World Health Organization by the following criteria:

•  Callous unconcern for the feelings of others and lack of the capacity for empathy.

•  Gross and persistent attitude of irresponsibility and disregard for social norms, rules, and obligations.

•  Incapacity to maintain enduring relationships.

•  Very low tolerance to frustration and a low threshold for discharge of aggression, including violence.

•  Incapacity to experience guilt and to profit from experience, particularly punishment.

•  Marked proneness to blame others or to offer plausible rationalizations for the behavior bringing the subject into conflict.

•  Persistent irritability.

Much research into psychopathy, as operationalized by the Hare Psychopathy Checklist Revised (PCL-R), has been conducted. The checklist assesses both interpersonal and affective components as well as lifestyle and antisocial deficits. However, the research results cannot be easily extrapolated to the clinical diagnoses of dissocial personality disorder or antisocial personality disorder. A sample research finding is that between 50% and 80% of prisoners in England and Wales meet the diagnostic criteria of dissocial personality disorder, but only 15% would be predicted to be psychopathic as measured by the PCL-R. Therefore, the findings drawn from psychopathy research have not yet been shown to be relevant as an aid to the diagnosis and treatment of dissocial or antisocial personality disorders.

Attempts to correlate dissocial personality disorder have had methodological problems. Although a high percentage of prisoners in England and Wales were shown in one survey to fulfill the criteria for a dissocial personality, since the diagnosis of dissocial personality includes a disregard for social rules and norms, it is not surprising that the same individuals commit crimes.

Research has been done attempting to assess the co-morbidity of dissocial personality disorder with other conditions. However, the few studies that have been done use too many different methodologies to enable forming solid conclusions, although it seems that there is a low prevalence of antisocial personality disorder/dissocial personality disorder in psychiatric hospitals.

In practice, mental health professionals rarely treat dissocial personality disorders as they are considered untreatable and no interventions have proven to be effective. In England and Wales the diagnosis is grounds for detention in secure psychiatric hospitals under the Mental Health Act if individuals with that diagnosis have committed serious crimes, but since such individuals are disruptive for other patients and not responsive to treatment this alternative to prison is not often used.

Emotionally Unstable Personality Disorder
is a medical diagnosis equivalent to American Psychiatric Association's (APA) Borderline personality disorder (BPD) but belonging to the ICD-10 system of classification. The diagnostic criteria differ slightly from that of the DSM-IV-TR system used by the APA for BPD.

diagnostic criteria Impulsive type

The general criteria for personality disorder (F60) must be met. [see below]
At least three of the following must be present, one of which must be (2):

marked tendency to act unexpectedly and without consideration of the consequences;

marked tendency to quarrelsome behaviour and to conflicts with others, especially when impulsive acts are thwarted or criticized;

liability to outbursts of anger or violence, with inability to control the resulting behavioural explosions;

difficulty in maintaining any course of action that offers no immediate reward;

unstable and capricious mood.

Borderline type
The general criteria for personality disorder (F60) must be met. [see below]
At least three of the symptoms mentioned in criterion 2 for F60.30 must be present [see above], with at least two of the following in addition:

disturbances in and uncertainty about self-image, aims, and internal preferences (including sexual);

liability to become involved in intense and unstable relationships, often leading to emotional crisis;
excessive efforts to avoid abandonment;

recurrent threats or acts of self-harm;

chronic feelings of emptiness.

F60 Disorders of adult personality and behaviour
There is evidence that the individual's characteristic and enduring patterns of inner experience and behaviour as a whole deviate markedly from the culturally expected and accepted range (or "norm"). Such deviation must be manifest in more than one of the following areas:

cognition (i.e. ways of perceiving and interpreting things, people, and events; forming attitudes and images of self and others);

affectivity (range, intensity, and appropriateness of emotional arousal and response);
control over impulses and gratification of needs;

manner of relating to others and of handling interpersonal situations
The deviation must manifest itself pervasively as behaviour that is inflexible, maladaptive, or otherwise dysfunctional across a broad range of personal and social situations (i.e. not being limited to one specific "triggering" stimulus or situation).

There is personal distress, or adverse impact on the social environment, or both, clearly attributable to the behaviour referred to in criterion 2.

There must be evidence that the deviation is stable and of long duration, having its onset in late childhood or adolescence.

The deviation cannot be explained as a manifestation or consequence of other adult mental disorders, although episodic or chronic conditions from sections F00-F59 or F70-F79 of this classification may coexist with, or be superimposed upon, the deviation.

Organic brain disease, injury, or dysfunction must be excluded as the possible cause of the deviation. (If an organic causation is demonstrable, category F07.- should be used.)

See also
Personality: What makes you the way you are?
What is OCD?
Panic attacks
Autism Activism
Cognitive Behavioural Therapy
Judgements on Mental Health
Creativity and Imagination
Bullying and peer abuse in school and the workplace
Genius or Psychotic
The causes of sexual orientation
Early Onset Dementia

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