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Chapter 18. Personality Disorders


John W. Barnhill, M.D.

Personality is the enduring pattern of behavior and inner experience. It underlies how we

think, feel, and act and frames how we view ourselves and the people around us. When we

think of who we are, we often think of personality as the central defining characteristic.

Psychiatrists and other mental health practitioners spend considerable time thinking about

personality and the ways in which dysfunctional personalities cause distress and

dysfunction in individuals and in the people around them. Disorders of personality are, in

some ways, as complex as humanity, itself full of idiosyncrasies, half-articulated conflicts,

and unknowable complexities.
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Like many other complex systems, however, personalities and personality disorders tend to

fall into patterns, and, for generations, clinicians and personality researchers from a variety

of fields have searched for a holy grail: a nosological system that is both simple to use and

sophisticated enough to capture the nuances and paradoxes of human personality.

Traditionally, the field of psychiatry has conceptualized personality disorders categorically,

as reflecting distinct clinical syndromes. In another paradigm, personality disorders are

conceptualized dimensionally, as dysfunctional variants of human personality traits that

exist on a gradient from maladaptive to normal. As part of the DSM-5 development

process, a team of personality researchers explored multiple ways to incorporate both

paradigms, and as a result created a new hybrid categorical-dimensional model.

After vigorous debate among team members, the DSM-5 text includes the traditional

categorical model of personality disorders as well as the new hybrid categorical-

dimensional model. It is the traditional categorical perspective that is included in the main

body of the text, while the alternative DSM-5 model for personality disorders is described

in Section III, “Emerging Measures and Models.” This decision means that the 10 DSM-IV

personality disorders—and their criteria—remain essentially unchanged. The primary

substantive change is that as part of the removal of the axial system, the personality

disorders are no longer listed separately from other DSM-5 diagnoses.

To better understand the similarities and differences of the two models, it may be useful to

explore how the two DSM-5 diagnostic systems recommend that a clinician assess a patient

with, for example, obsessive-compulsive personality disorder (OCPD). From a categorical

perspective, the individual would receive a diagnosis of OCPD when certain criteria were

met. First, the clinician should identify a persistent, dysfunctional pattern of, for instance,

perfectionism at the expense of flexibility. The clinician would then identify at least four of

seven specific symptomatic criteria (preoccupation with lists, inability to delegate tasks,

stubbornness, etc.) and search for disorders that might be responsible for the same

symptoms (and that could lead to either the coding of the other diagnosis only, such as

when schizophrenia causes symptoms akin to those found in OCPD, or the coding of both

diagnoses, such as when the person also meets criteria for another personality disorder).

The new DSM-5 hybrid model reshapes the 10 DSM-IV personality disorder categories into

a roster of six redefined categories (antisocial, avoidant, borderline, narcissistic, obsessive-

compulsive, and schizotypal). For each of the six, the hybrid model requires two

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assessments. The first involves a determination that the individual has significant

impairment in at least two of four personality functioning areas: identity, self-direction,

empathy, and intimacy. For each of the six personality disorders, these personality specifics

differ. For example, to qualify for OCPD, an individual might be found to have significant

impairment from a sense of self excessively derived from work (identity) and from rigidity

and stubbornness negatively affecting relationships (intimacy).

The new hybrid model then requires an assessment of personality traits that are organized

under five broad trait domains. As shown in 18-, these traits and trait domains exist on a

spectrum; for example, for one of the five trait domains, antagonism lies on one end of the

spectrum and agreeableness on the other. These five broad trait domains are new to many

psychiatrists, but they have been rigorously studied for several decades within academic

psychology under the rubric of the Five Factor Model, whose personality dimensions

include neuroticism, extraversion, agreeableness, conscientiousness, and openness. For

each of these personality dimensions, there are clusters of related personality traits.

Applied to a particular person, the Five Factor Model can assign a percentile score for each

trait. For example, the theoretical person with OCPD might score in the 95th percentile for

conscientiousness and in the 5th percentile for openness. DSM-5 adapted these personality

dimensions and traits in order to more specifically focus on psychiatric disorder.

Alternative DSM-5 model: pathological personality trait domains

Enlarge table

Twenty-five specific pathological personality traits are included under the umbrella of these

five negative trait domains. For each of the personality disorders, DSM-5 requires that the

individual demonstrate most of the typical personality traits. For example, the patient with

OCPD must demonstrate the trait of rigid perfectionism (an aspect of the trait domain of

conscientiousness) as well as at least two of the following three traits: perseveration (an

aspect of negative affectivity), intimacy avoidance (an aspect of detachment), and restricted

affectivity (also an aspect of detachment).

The DSM-5 hybrid model also specifies that specific traits can be recorded even if not

recognized as part of a diagnosed personality disorder (e.g., hostility, a trait associated with

the trait domain of negative affectivity, could be listed alongside any DSM-5 diagnosis and

not be considered just a trait associated with, for instance, antisocial personality disorder).

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Both of the DSM-5 models have advantages and disadvantages. The new DSM-5 hybrid

model might contribute to a more nuanced understanding of patients, and its approach

takes advantage of decades’ worth of personality research. Its current complexity is

daunting, however, even to seasoned clinicians, and the use of a new system would

potentially reduce the usefulness of existing research data within psychiatry.

The traditional categorical paradigm has been critiqued for excessive comorbidity and

intradisorder heterogeneity, as well as for the fact that one of the most common personality

disorder diagnoses in the past has been “personality disorder not otherwise specified,”

which is clarified only marginally by the DSM-5 use of “other specified” and “unspecified”

personality disorders. On the other hand, the categorical approach is relatively

straightforward to use, is familiar from DSM-IV, and follows the categorical structure used

throughout the rest of DSM-5. It is also the personality model included in the main body of

the DSM-5 text and, as such, remains the American Psychiatric Association’s official

perspective on personality disorders.

Suggested Readings

MacKinnon RA, Michels R, Buckley PJ: The Psychiatric Interview in Clinical Practice, 2nd

Edition. Washington, DC, American Psychiatric Publishing, 2006

Michels R: Diagnosing personality disorders. Am J Psychiatry 169(3):241–243, 2012

PubMed ID: 22407109

Shedler J, Beck A, Fonagy P, et al: Personality disorders in DSM-5. Am J Psychiatry

167(9):1026–1028, 2010 PubMed ID: 20826853

Skodol AE, Bender DS, Oldham JM, et al: Proposed changes in personality and

personality disorder assessment and diagnosis for DSM-5, part II: clinical application.

Personal Disord 2(1):23–30, 2011 PubMed ID: 22448688

Skodol AE, Clark LA, Bender DS, et al: Proposed changes in personality and personality

disorder assessment and diagnosis for DSM-5, part I: description and rationale. Personal

Disord 2(1):4–22, 2011 PubMed ID: 22448687

Westen D, Shedler J, Bradley B, DeFife JA: An empirically derived taxonomy for

personality diagnosis: bridging science and practice in conceptualizing personality. Am J

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Psychiatry 169(3):273–284, 2012 PubMed ID: 22193534

Case 18.1 Personality Con�icts

Larry J. Siever, M.D.

Lauren C. Zaluda, B.A.

Frazier Archer was a 34-year-old single white man who called a mood and personality

disorders research program because an ex-friend had once said he was “borderline,” and

Mr. Archer wanted to learn more about his personality conflicts.

During his diagnostic research interviews, Mr. Archer reported regular, almost daily

situations in which he was sure he was being lied to or deceived. He was particularly wary

of people in leadership positions and people who had studied psychology and, therefore,

had “training to understand the human mind,” which they used to manipulate people.

Unlike those around him, Mr. Archer believed he did not “drink the Kool-Aid” and was able

to detect manipulation and deceit.

Mr. Archer was extremely detail oriented at work, and had trouble delegating and

completing tasks. Numerous employers had told him that he focused excessively on rules,

lists, and small details, and that he needed to be more friendly. He had held numerous jobs

over the years, but he was quick to add, “I’ve quit as often as I’ve been fired.” During the

interview, he defended his behavior, asserting that unlike many people, he understood the

value of quality over productivity. Mr. Archer’s wariness had contributed to his “bad

temper” and emotional “ups and downs.” He socialized only “superficially” with a handful

of acquaintances and could recall the exact moments when previous “so-called friends and

lovers” had betrayed him. He spent most of his time alone.

Mr. Archer denied any significant history of trauma, any current or past problems with

substance use, and any history of head trauma or loss of consciousness. He also denied any

history of mental health diagnosis or treatment, but reported that he felt he might have a

mental health condition that had not yet been diagnosed.

On mental status examination, Mr. Archer appeared well groomed, cooperative, and

oriented. His speech varied; at times he would pause thoughtfully prior to answering

questions, causing his rate of speech to be somewhat slow. His tone also changed

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significantly when he discussed situations that had made him angry, and many of his

responses were lengthy, digressive, and vague. However, he seemed generally coherent and

did not evidence perceptual disorder. His affect was occasionally inappropriate (e.g.,

smiling while crying) but generally constricted. He reported apathy as to whether he lived

or died but did not report any active suicidal ideation or homicidal ideation.

Notably, Mr. Archer became irritated and argumentative with research staff when he was

told that although he could receive verbal feedback on his interviews, he could not receive a

copy of completed questionnaires and diagnostic tools. He commented that he would

document in his personal records that research staff were refusing him the forms.


Paranoid personality disorder

Obsessive-compulsive personality disorder


Mr. Archer describes a long-standing, inflexible, dysfunctional pattern of dealing with the

world. He demonstrates an enduring pattern of distrust and suspiciousness. He believes

that others are exploiting or deceiving him; doubts the loyalty of friends; bears grudges;

and recurrently mistrusts the fidelity of sexual partners. This cluster of symptoms qualifies

him for DSM-5 paranoid personality disorder (PPD).

A second cluster of personality traits relates to Mr. Archer’s preoccupation with

perfectionism and control. He is excessively focused on rules, lists, and details. He is

inflexible and unable to delegate. In addition to PPD, he has DSM-5 obsessive-compulsive

personality disorder (OCPD).

For any of the personality disorders, it is important to exclude the physiological effects of a

substance or another medical condition; neither of these appears likely in Mr. Archer, who

denied all substance abuse, medical illness, and head injury. Furthermore, his patterns of

behavior appear to be enduring and not related to either a major change in life

circumstance or another psychiatric disorder.

It is unsurprising that in addition to the PPD and OCPD diagnoses, Mr. Archer meets

partial criteria for other personality disorders, including schizotypal, borderline,

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narcissistic, and avoidant personality disorders. Personality disorders are frequently

comorbid, and if a patient meets criteria for more than one disorder, each should be

recorded. PPD is especially unlikely to be an isolated diagnosis, in either clinical or

research populations. PPD is often comorbid with schizotypal personality disorder and/or

other schizophrenia spectrum disorders, a finding attributable to overlapping paranoia-

related criteria. In Mr. Archer’s case, his emotional instability, anxiety, anger, and

arrogance are symptoms often found in a personality cluster that includes borderline

personality disorder and narcissistic personality disorder. Because of the relative

infrequency of PPD as an “isolated” disorder, current research is pointing toward the

possibility that some personality disorders, including PPD, could be consolidated to create

more inclusive diagnoses. Paranoia would then be viewed as a specifier or modifier for

other disorders. That is not the situation with DSM-5, however, and PPD should continue

to be listed as a comorbid condition when criteria are met.

A second interesting diagnostic issue related to PPD is the concern among some clinicians

that diagnosing PPD is tantamount to trying to identify an early stage of schizophrenia.

There is genetic, neurobiological, epidemiological, and symptomatic evidence that PPD,

like schizotypal personality disorder, is related to schizophrenia and lies on the

schizophrenia spectrum. However, PPD is not a precursor to schizophrenia, and its

symptoms are not indicative of the prodromal phase of schizophrenia. Prodromal

schizophrenia is best characterized by early psychotic symptoms, including disorganized

thoughts and behavior, whereas the thought patterns in PPD are generally more similar to

those of delusional disorder and related thought disorders.

Suggested Readings

Berman ME, Fallon AE, Coccaro EF: The relationship between personality

psychopathology and aggressive behavior in research volunteers. J Abnorm Psychol

107(4):651–658, 1998 PubMed ID: 9830252

Bernstein D, Useda D, Siever L: Paranoid personality disorder, in The DSM-IV

Personality Disorders. Edited by Livesley WJ. New York, Guilford, 1995, pp 45–57

Kendler KS: Diagnostic approaches to schizotypal personality disorder: a historical

perspective. Schizophr Bull 11(4):538–553, 1985 PubMed ID: 3909377

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Kendler KS, Neale MC, Walsh D: Evaluating the spectrum concept of schizophrenia in the

Roscommon Family Study. Am J Psychiatry 152(5):749–754, 1995 PubMed ID: 7726315

Siever LJ, Davis KL: The pathophysiology of schizophrenia disorders: perspectives from

the spectrum. Am J Psychiatry 161(3):398–413, 2004 PubMed ID: 14992962

Siever LJ, Koenigsberg HW, Harvey P, et al: Cognitive and brain function in schizotypal

personality disorder. Schizophr Res 54(1–2):157–167, 2002 PubMed ID: 11853990

Thaker GK, Ross DE, Cassady SL, et al: Saccadic eye movement abnormalities in relatives

of patients with schizophrenia. Schizophr Res 45(3):235–244, 2000 PubMed ID:


Triebwasser J, Chemerinski E, Roussos P, Siever L: Paranoid personality disorder. J Pers

Disord August 28, 2012 [Epub ahead of print] PubMed ID: 22928850

Zimmerman M, Chelminski I, Young D: The frequency of personality disorders in

psychiatric patients. Psychiatr Clin North Am 31(3):405–420, 2008 PubMed ID:


Case 18.2 Oddly Isolated

Salman Akhtar, M.D.

Grzegorz Buchalski was an 87-year-old white man who was brought to the psychiatric

emergency room (ER) by paramedics after they had been called to his apartment by

neighbors when they noticed an odd smell. Apparently, his 90-year-old sister had died

some days earlier after a lengthy illness. Mr. Buchalski had delayed reporting her death for

several reasons. He had become increasingly disorganized as his sister’s health had

worsened, and he was worried that his landlord would use the apartment’s condition as a

pretext for eviction. He had tried to clean up, but his attempts consisted mainly of moving

items from one place to another. He said he was about to call for help when the police and

paramedics showed up.

In the ER, Mr. Buchalski recognized that his actions were odd and that he should have

called for help sooner. At times, he became tearful when discussing the situation and his

sister’s death; at other times, he seemed aloof, speaking about these in a calm, factual way.

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He also wanted to clarify that his apartment had indeed been a mess but that much of the

apparent mess was actually his large collection of articles on bioluminescence, a topic he

had been researching for decades.

A licensed plumber, electrician, and locksmith, Mr. Buchalski had worked until age 65. He

described his late sister as having been always “a little strange.” She had never worked and

had been married once, briefly. Aside from the several-month marriage, she and Mr.

Buchalski had lived in the family’s two-bedroom Manhattan apartment their entire lives.

Neither of them had ever seen a psychiatrist.

When questioned, Mr. Buchalski stated that he had never had a romantic or sexual

relationship and had never had many friends or social contacts outside his family. He

explained that he had been poor and Polish and had had to work all the time. He had taken

night classes to better understand “the strange world we live in,” and he said his intellectual

interests were what he found most gratifying. He said he had been upset as he realized that

his sister was dying, but he would call it “numb” rather than depressed. He also denied any

history of manic or psychotic symptoms. After an hour with the psychiatric trainee, Mr.

Buchalski confided that he hoped the medical school might be interested in some of his

papers after his death. He said he believed that bioluminescent and genetic technologies

were on the verge of a breakthrough that might allow the skin of animals and then humans

to glow in subtle colors that would allow people to more directly recognize emotions. He

had written the notes for such technology, but they had grown into a “way-too-long science

fiction novel with lots of footnotes.”

On examination, Mr. Buchalski was a thin, elderly man dressed neatly in khakis and

button-down shirt. He was meticulous and much preferred to discuss his interests in

science than his own story. He made appropriate eye contact and had a polite, pleasant

demeanor. His speech was coherent and goal directed. His mood was “fine,” and his affect

was appropriate though perhaps unusually cheerful under the circumstances. He denied all

symptoms of psychosis, depression, and mania. Aside from his comments about

bioluminescence, he said nothing that sounded delusional. He was cognitively intact, and

his insight and judgment were considered generally good, although historically impaired in

regard to his delay in calling the police about his sister.


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Schizoid personality disorder


Mr. Buchalski’s aloof, taciturn, and asexual lifestyle certainly fit the diagnostic criteria for

schizoid personality disorder; his explanation that he has been friendless because he is

Polish and poor is a weak rationalization for his psychosocial deficits. The eccentricity of

his interest in bioluminescence, the exaggerated estimation of the value of his “papers,” and

the fact that he has lived pretty much all his life in the family’s residence with his sister give

further evidence of his inward preoccupation and lack of social engagement. The striking

poverty of his emotional response at his sister’s passing away and his failure to make any

sort of funeral arrangements are confirmatory of a flattened affective life and weak ego

skills. The fact that he is cognitively intact rules out a gradually occurring, dementing

etiology for his withdrawal and “confirms” the diagnosis of schizoid personality disorder.

Such a diagnosis has a long history in psychiatry and psychoanalysis. In psychiatry, its

origins go back to Eugen Bleuler, who coined the term schizoid in 1908 to describe a natural component of personality that pulled one’s attention toward one’s inner life and

away from the external world. He labeled a morbid exaggeration of this tendency as

“schizoid personality.” Such individuals were described as quiet, suspicious, and

“comfortably dull.” Bleuler’s description was elaborated upon over the next century, and

many features were added to it. These included solitary lifestyle, love of books, lack of

athleticism, tendency toward autistic thinking, poorly developed sexuality, and covert but

intense sensitivity to others’ emotional responses. This last feature, however, got dropped

from the more recent portrayals of schizoid personality, including the ones in DSM-III and

DSM-IV. Despite the reservations of many investigators (e.g., Otto Kernberg, John

Livesley, and myself), “lacking desire for close relationships” became a prime criterion for

the schizoid diagnosis. Among other factors that were emphasized were asexuality,

indifference to praise or criticism, anhedonia, and emotional coldness. The hypersensitivity

criterion and the ostensible link to schizophrenia were assigned, respectively, to the

categories of “avoidant” and “schizotypal” personality disorders.

Within psychoanalysis, the schizoid condition was best described by W. R. D. Fairbairn and

Harry Guntrip. According to them, intense sensitivity to both love and rejection and a

propensity to readily withdraw from interpersonal relatedness lay at the core of schizoid

pathology. The individual thus afflicted oscillated between wanting closeness and dreading

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it; feared the vigor of his or her own needs and their impact on others; and was attracted to

literary and artistic activities because these were avenues of self-expression without direct

human contact. Schizoid personality evolved from one or more of the following scenarios:

1) tantalizing refusal by early caretakers that aroused frightening amounts of emotional

hunger; 2) chronic parental rejection, which resulted in compliant apathy and lifelessness;

and 3) sustained neglect by parents, which led to retreat into the fantasy world.

The absence of developmental history and of any data about Mr. Buchalski’s childhood

weakens a psychodynamic understanding of Mr. Buchalski’s schizoid personality. However,

developmental history is not a required criterion for a descriptive diagnosis; this criterion

is primarily utilized by psychodynamically oriented psychiatrists. All in all, the diagnosis of

schizoid personality disorder seems reasonable for Mr. Buchalski, although some might

argue in favor of a schizotypal personality disorder diagnosis given the oddity of his

interests. If further exploration yields information that qualifies this patient for both

personality disorders, then both should be recorded.

In regard to other comorbidities, the most likely appears to be hoarding disorder, a

diagnosis new to DSM-5. Mr. Buchalski indicates that he delayed calling the police after his

sister died because he was worried that his landlord would use the condition of the

apartment as a pretext for eviction. He describes a large collection of bioluminescence

papers, for example, a statement that could mean a 2-foot-tall stack of manuscripts or an

apartment crammed to the ceilings with decades’ worth of newspapers, magazines, and

scribbled notes, saved because of their potential usefulness. Clarifying the presence of this

(or any other) comorbid condition would be crucial to the development of a treatment plan

that tries to maximize the likelihood of independent happiness for this patient.

Suggested Readings

Akhtar S: Schizoid personality disorder: a synthesis of developmental, dynamic, and

descriptive features. Am J Psychother 41(4):499–518, 1987 PubMed ID: 3324773

Livesley WJ, West M, Tanney A: A historical comment on DSM-III schizoid and avoidant

personality disorders. Am J Psychiatry 142(11):1344–1347, 1985 PubMed ID: 3904489

Triebwasser J, Chemerinski E, Roussos P, Siever LJ: Schizoid personality disorder. J Pers

Disord 26(6):919–926, 2012 PubMed ID: 23281676

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Case 18.3 Worried and Oddly Preoccupied

Kristin Cadenhead, M.D.

Henry, a 19-year-old college sophomore, was referred to the student health center by a

teaching assistant who noticed that he appeared odd, worried, and preoccupied and that

his lab notebook was filled with bizarrely threatening drawings.

Henry appeared on time for the psychiatric consultation. Although suspicious about the

reason for the referral, he explained that he generally “followed orders” and would do what

he was asked. He agreed that he had been suspicious of some of his classmates, believing

they were undermining his abilities. He said they were telling his instructors that he was “a

weird guy” and that they did not want him as a lab partner. The referral to the psychiatrist

was, he said, confirmation of his perception.

Henry described how he had seen two students “flip a coin” over whether he was gay or

straight. Coins, he asserted, could often predict the future. He had once flipped a coin and

“heads” had predicted his mother’s illness. He believed his thoughts often came true.

Henry had transferred to this out-of-town university after an initial year at his local

community college. The transfer was his parents’ idea, he said, and was part of their agenda

to get him to be like everyone else and go to parties and hang out with girls. He said all such

behavior was a waste of time. Although they had tried to push him into moving into the

dorms, he had refused, and instead lived by himself in an off-campus apartment.

With Henry’s permission, his mother was called for collateral information. She said Henry

had been quiet, shy, and reserved since childhood. He had never had close friends, had

never dated, and had denied wanting to have friends. He acknowledged feeling depressed

and anxious at times, but these feelings did not improve when he was around other people.

He was teased by other kids and would come home upset. His mother cried while

explaining that she always felt bad for him because he never really “fit in,” and that she and

her husband had tried to coach him for years without success. She wondered how a person

could function without any social life.

She added that ghosts, telepathy, and witchcraft had fascinated Henry since junior high

school. He had long thought that he could change the outcome of events like earthquakes

and hurricanes by thinking about them. He had consistently denied substance abuse, and

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two drug screens had been negative in the prior 2 years. She mentioned that her

grandfather had died in an “insane asylum” many years before Henry was born, but she did

not know his diagnosis.

On examination, Henry was tall, thin, and dressed in jeans and a T-shirt. He was alert and

wary and, although nonspontaneous, he answered questions directly. He denied feeling

depressed or confused. Henry denied having any suicidal thoughts, plans, or attempts. He

denied having any auditory or visual hallucinations, panic attacks, obsessions,

compulsions, or phobias. His intellectual skills seemed above average, and his Mini-Mental

State Examination score was 30 out of 30.


Schizotypal personality disorder

Paranoid personality disorder


Henry presents with a pattern of social and interpersonal deficits accompanied by

eccentricities and cognitive distortions. These include delusional-like symptoms (magical

thinking, suspiciousness, ideas of reference, grandiosity), eccentric interests, evidence of

withdrawal (few friends, avoidance of social contact), and restricted affect (emotional

coldness). Therefore, Henry appears to meet criteria for DSM-5 schizotypal personality


Henry also suspects that others are undermining him, reads hidden meaning into benign

activities, bears grudges, and is overly sensitive to perceived attacks on his character. In

addition to schizotypal personality disorder, he meets criteria for paranoid personality

disorder. If an individual meets criteria for two personality disorders—as is often the case—

both should be recorded.

Henry, however, is only 19 years old, and a personality disorder diagnosis should be made

only after exploring other diagnoses that could produce similar symptoms. For example,

Henry’s deficits in social communication and interaction could be consistent with a

diagnosis of autism spectrum disorder (ASD) without intellectual impairment. It is possible

that he had unreported symptoms beyond “shyness” in the early developmental period,

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and, as was reported about Henry, children with ASD commonly undergo schoolyard

teasing. He and his mother do not, however, report the sorts of restricted, repetitive

patterns of behavior, interests, or activities that are also a hallmark of ASD. Without these,

Henry would not be diagnosed on the autism spectrum.

Henry also may have a psychiatric disorder that develops in young adulthood, and he is at

the peak age for the onset of depressive, bipolar, and anxiety disorders. Any of these can

exacerbate baseline personality traits and make them appear to be disorders, but Henry

does not appear to have significant depressive, manic, or anxiety symptoms.

More likely in this case would be a diagnosis on the schizophrenia spectrum. For Henry to

have an actual schizophrenia diagnosis, however, he would need to have two or more of the

following five criteria: delusions, hallucinations, disorganized speech, grossly disorganized

or catatonic behavior, and negative symptoms. Because he denies hallucinations and

appears to be logical and not to have either odd behavior or negative symptoms, he does

not have schizophrenia. Instead, he may have delusions—and it would be useful to clarify

the extent to which he has fixed, false beliefs about predicting and affecting the future—but

his beliefs seem more bizarre than those typically seen in delusional disorder.

Although Henry currently may best fit the two personality disorder diagnoses listed above,

he may go on to develop a more explicitly psychotic disorder. Psychiatric clinicians and

researchers are particularly interested in distinguishing individuals who present as unusual

as teenagers and are likely to go on to develop a more disabling schizophrenia from those

who present similarly but will not go on to develop a major psychiatric disorder. Although

the current ability to predict schizophrenia is not robust, early intervention could

substantially reduce the psychological suffering and the long-term functional

consequences. To that end, DSM-5 Section III includes attenuated psychosis syndrome as

one of the conditions for further study. Attenuated psychosis syndrome focuses on

subsyndromal symptoms, including impaired insight and functionality, in an effort to

clarify which patients are in the process of a decline into schizophrenia and which patients

are demonstrating the beginnings of a more crystallized personality disorder.

Suggested Readings

Addington J, Cornblatt BA, Cadenhead KS, et al: At clinical high risk for psychosis:

outcome for nonconverters. Am J Psychiatry 168(8):800–805, 2011 PubMed ID:

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Ahmed AO, Green BA, Goodrum NM, et al: Does a latent class underlie schizotypal

personality disorder? Implications for schizophrenia. J Abnorm Psychol 122(2):475–491,

2013 PubMed ID: 23713503

Fisher JE, Heller W, Miller GA: Neuropsychological differentiation of adaptive creativity

and schizotypal cognition. Pers Individ Dif 54(1):70–75, 2013 PubMed ID: 23109749

Case 18.4 Unfairness

Charles L. Scott, M.D.

Ike Crocker was a 32-year-old man referred for a mental health evaluation by the human

resources department of a large construction business that had been his employer for 2

weeks. At his initial job interview, Mr. Crocker presented as very motivated and provided

two carpentry school certifications that indicated a high level of skill and training. Since his

employment began, his supervisors had noted frequent arguments, absenteeism, poor

workmanship, and multiple errors that might have been dangerous. When confronted, he

was reportedly dismissive, indicating that the problem was “cheap wood” and “bad

management” and added that if someone got hurt, “it’s because of their own stupidity.”

When the head of human resources met with him to discuss termination, Mr. Crocker

quickly pointed out that he had both attention-deficit/hyperactivity disorder (ADHD) and

bipolar disorder. He said that if not granted an accommodation under the Americans with

Disabilities Act, he would sue. He demanded a psychiatric evaluation.

During the mental health evaluation, Mr. Crocker focused on unfairness at the company

and on how he was “a hell of a better carpenter than anyone there could ever be.” He

claimed that his two marriages had ended because of jealousy. He said that his wives were

“always thinking I was with other women,” which is why “they both lied to judges and got

restraining orders saying I’d hit them.” As “payback for the jail time,” he refused to pay

child support for his two children. He had no interest in seeing either of his two boys

because they were “little liars” like their mothers.

Mr. Crocker said he “must have been smart” because he had been able to make Cs in school

despite showing up only half the time. He spent time in juvenile hall at age 14 for stealing

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“kid stuff, like tennis shoes and wallets that were practically empty.” He left school at age 15

after being “framed for stealing a car” by his principal. Mr. Crocker pointed out these

historical facts as evidence that he was able to overcome injustice and adversity.

In regard to substance use, Mr. Crocker said he smoked marijuana as a teenager and

started drinking alcohol on a “regular basis” after he first got married at age 22. He denied

that use of either substance was a problem.

Mr. Crocker concluded the interview by demanding a note from the examiner that he had

“bipolar” and “ADHD.” He said that he was “bipolar” because he had “ups and downs” and

got “mad real fast.” Mr. Crocker denied other symptoms of mania. He said he got down

when disappointed, but he had “a short memory” and “could get out of a funk pretty quick.”

Mr. Crocker reported no difficulties in his sleep, mood, or appetite. He learned about

ADHD because “both of my boys got it.” He concluded the interview with a request for

medications, adding that the only ones that worked were stimulants (“any of them”) and a

specific short-acting benzodiazepine.

On mental status examination, Mr. Crocker was a casually dressed white man who made

reasonable eye contact and was without abnormal movements. His speech was coherent,

goal directed, and of normal rate. There was no evidence of any thought disorder or

hallucinations. He was preoccupied with blaming others, but these comments appeared to

represent overvalued ideas rather than delusions. He was cognitively intact. His insight

into his situation was poor.

The head of human resources did a background check during the course of the psychiatric

evaluation. Phone calls revealed that Mr. Crocker had been expelled from two carpentry

training programs and that both his graduation certificates had been falsified. He had been

fired from his job at one local construction company after a fistfight with his supervisor and

from another job after abruptly leaving a job site. A quick review of their records indicated

that he had provided them with the same false documentation.


Antisocial personality disorder


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Mr. Crocker has a pervasive pattern of disregard for and violation of the rights of others, as

indicated by many different actions. He has been arrested twice for domestic violence—

once each from two separate marriages—and has spent time in jail. Mr. Crocker has

falsified his carpentry credentials and provides ample evidence of repeated fights and

irritability, both at work and within his relationships. He demonstrates little or no regard

for how his actions affect the safety of his coworkers. He refuses to see his young sons or

pay child support, because they are “little liars.” He exhibits no remorse for how his actions

negatively affect his family, coworkers, or employers. He routinely quits jobs and fails to

plan ahead for his next employment. He meets all seven of the symptomatic criteria for

DSM-5 antisocial personality disorder (APD).

The diagnosis of APD cannot be made until age 18, but it does require evidence for conduct

disorder before age 15. Mr. Crocker’s history indicates a history of truancy, adjudication for

theft at age 14, and expulsion from school at age 15 for car theft.

At the end of the evaluation, Mr. Crocker requests two potentially addictive medications.

He smoked marijuana in high school and may have begun to drink alcohol heavily in his

20s. Although it might be difficult to elicit an honest account of his substance use, Mr.

Crocker may indeed have a comorbid substance use disorder. Such a diagnosis would not

affect his diagnosis of APD, however, because his antisocial behavior predates his reported

use of substances. In addition, his antisocial attitudes and behaviors are manifest in

multiple settings and are not simply a result of his substance abuse (e.g., stealing to pay for

his drugs).

Mr. Crocker’s claim that he has ADHD would require evidence that he had some

hyperactive-impulsive or inattentive symptoms that caused impairment before age 12

years. Although ADHD could be a comorbid condition and could account for some of his

impulsivity, it would not account for his wide-ranging antisocial behavior.

The APD diagnosis also requires that the behavior not occur only during the course of

bipolar disorder or schizophrenia. Although Mr. Crocker states that he has bipolar

disorder, he provides no evidence that he has ever been manic (or schizophrenic).

Mr. Crocker’s interpersonal style is marked by callous disregard for the feelings of others

and an arrogant self-appraisal. Such qualities can be found in other personality disorders,

such as narcissistic personality disorder, but they are also common in APD. Although

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comorbidity is not uncommon, individuals with narcissistic personality disorder do not

exhibit the same levels of impulsivity, aggression, and deceit as are present in APD.

Individuals with histrionic personality disorder or borderline personality disorder may be

manipulative or impulsive, but their behaviors are not characteristically antisocial.

Individuals with paranoid personality disorder may demonstrate antisocial behaviors, but

their actions tend to stem from a paranoid desire for revenge rather than a desire for

personal gain. Finally, people with intermittent explosive disorder also get into fights, but

they lack the many exploitive traits that are a pervasive part of APD.

Suggested Readings

Edwards DW, Scott CL, Yarvis RM, et al: Impulsiveness, impulsive aggression, personality

disorder, and spousal violence. Violence Vict 18(1):3–14, 2003 PubMed ID: 12733616

Wygant DB, Sellbom M: Viewing psychopathy from the perspective of the Personality

Psychopathology Five model: implications for DSM-5. J Pers Disord 26(5):717–726, 2012

PubMed ID: 23013340

Case 18.5 Fragile and Angry

Frank Yeomans, M.D., Ph.D.

Otto Kernberg, M.D.

Juanita Delgado, a single, unemployed Hispanic woman, sought therapy at age 33 for

treatment of depressed mood, chronic suicidal thoughts, social isolation, and poor personal

hygiene. She had spent the prior 6 months isolated in her apartment, lying in bed, eating

junk food, watching television, and doing more online shopping than she could afford.

Multiple treatments had yielded little effect.

Ms. Delgado was the middle of three children in an upper-middle-class immigrant family in

which the father reportedly valued professional achievement over all else. She felt isolated

throughout her school years and experienced recurrent periods of depressed mood. Within

her family, she was known for angry outbursts. She had done well academically in high

school but dropped out of college because of frustrations with a roommate and a professor.

She attempted a series of internships and entry-level jobs with the expectation that she

would return to college, but she kept quitting because “bosses are idiots. They come across

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as great and they all turn out to be twisted.” These “traumas” always left her feeling terrible

about herself (“I can’t even succeed as a clerk?”) and angry at her bosses (“I could run the

place and probably will”). She had dated men when she was younger but never let them get

close physically because she become too anxious when any intimacy began to develop.

Ms. Delgado’s history included cutting herself superficially on a number of occasions, along

with persistent thoughts that she would be better off dead. She said that she was generally

“down and depressed” but that she had had dozens of 1- to 2-day “manias” in which she

was energized and edgy and pulled all-nighters. She tended to “crash” the next day and

sleep for 12 hours.

She had been in psychiatric treatment since age 17 and had been psychiatrically

hospitalized three times after overdoses. Treatments had consisted primarily of

medication: mood stabilizers, low-dose neuroleptics, and antidepressants that had been

prescribed in various combinations in the context of supportive psychotherapy.

During the interview, she was a casually groomed and somewhat unkempt woman who was

cooperative, coherent, and goal directed. She was generally dysphoric with a constricted

affect but did smile appropriately several times. She described shame at her poor

performance but also believed she was “on Earth to do something great.” She described her

father as a spectacular success, but he was also a “Machiavellian loser who was always

trying to manipulate people.” She described quitting jobs because people were

disrespectful. For example, she said that when she worked as a clerk at a department store,

people would often be rude or unappreciative (“and I was there only in preparation to

become a buyer; it was ridiculous”). Toward the end of the initial session, she became angry

with the interviewer after he glanced at the clock (“Are you bored already?”). She said she

knew people in the neighborhood, but most of them had “become frauds or losers.” There

were a few people from school who were “Facebook friends,” doing amazing things all over

the world. Although she had not seen them in years, she intended to “meet up with them if

they ever come back to town.”


Borderline personality disorder


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Ms. Delgado presents with affective instability, difficulty controlling her anger, unstable

interpersonal relationships, an identity disturbance, self-mutilating behavior, feelings of

emptiness, and transient, stress-related paranoia. She meets criteria, therefore, for DSM-5

borderline personality disorder (BPD).

Individuals with BPD often present with depressive and/or bipolar symptoms, and Ms.

Delgado is no exception. Her presenting symptoms include a predominantly depressed

mood, diminished interests, overeating, anergia, and chronic suicidal ideation. Disabling,

persistent for 6 months, and occurring in the absence of substance use or a medical

disorder, Ms. Delgado’s symptoms also meet criteria for a DSM-5 major depression. Such

comorbidity between BPD and depression is common. It is interesting to note that Ms.

Delgado’s preoccupations are accusatory, whereas the typical preoccupation of a depressed

person without a personality disorder is guilty and self-accusatory. It would be worth

exploring the possibility that Ms. Delgado’s depressive symptoms are more episodic and

reactive than she initially reports. It also seems possible that she qualifies for lifelong

depression, which would indicate dysthymic disorder but would also point toward a

personality disorder.

Ms. Delgado reports “manias” that are not typical of someone with bipolar disorder. For

example, she describes having had dozens of 1- to 2-day episodes in which she is energized

and edgy, followed by a “crash” and 12 hours of sleep. These do not conform to the criteria

for bipolar I or bipolar II disorder, in regard to either symptoms or duration. The

emotional instability and affect storms of BPD can look very much like a manic or

hypomanic episode, which can lead to underdiagnosis of BPD. Even in the presence of a

significant manic episode, the clinician should explore such historical variables as affective

stability, maturity of interpersonal relationships, and stability of work, relationships, and

self-assessment. If problems are found, a BPD diagnosis is likely.

Criteria for DSM-5 personality disorders remain unchanged from the previous

classification system. However, the alternative model for personality disorders, presented

in DSM-5 Section III, suggests a more dimensional approach, one in which the interviewer

would explicitly consider personality functioning. The appendix outlines five different trait

domains that exist on a continuum. “Emotional stability” is contrasted with “negative

affectivity,” for example, whereas “antagonism” is at the other end of the spectrum from

“agreeableness” (see Table 18- in the introduction to this chapter).

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This dimensional view of personality is compatible with Kernberg’s long-standing model of

borderline personality organization (BPO). In addition to meeting the DSM-5 criteria for

BPD, Ms. Delgado fits the criteria for BPO —a psychological structure conceived as being

characterized by 1) lack of a clear and coherent sense of self and others (identity diffusion),

2) frequent use of primitive defense mechanisms based on splitting, and 3) intact but

fragile reality testing. The more integrated and realistically complex the individual’s

representations of self and others are, the more the individual is able to modulate and

control his or her emotional states and successfully interact with others.

Ms. Delgado demonstrates identity diffusion in her contradictory views of herself (as both

superior and inadequate) and others (her father as both spectacular and a “Machiavellian

loser”). Her defensive style is characterized by consistent projection of her hostile feelings

and perceiving the hostility as coming from others. The fragility of her reality testing, seen

in the slights she felt at work, has led to chronic occupational dysfunction.

Because people with personality disorders often do not present an interpersonal narrative

that conforms to the story that would be told by others, it is important to attend to the

patient’s behavior in relation to the therapist. With Ms. Delgado, evidence of her fragility is

seen in her sense that the therapist’s glancing at the clock meant he did not like her and

wanted to get rid of her.

Suicidal tendencies are part of both depression and BPD. In general, acute or chronic

parasuicidal behavior is typical of severe personality disorders. Furthermore, suicidality

can develop abruptly during crises among a variety of patients, but it is especially prevalent

in people—like Ms. Delgado—with a fragile sense of both the world and themselves.

Suggested Readings

Clarkin JF, Yeomans FE, Kernberg OF: Psychotherapy for Borderline Personality:

Focusing on Object Relations. Washington, DC, American Psychiatric Publishing, 2006

Kernberg OF, Yeomans FE: Borderline personality disorder, bipolar disorder, depression,

attention deficit/hyperactivity disorder, and narcissistic personality disorder: practical

differential diagnosis. Bull Menninger Clin 77(1):1–22, 2013 PubMed ID: 23428169

Oldham JM, Skodol AE, Bender DS (eds): American Psychiatric Publishing Textbook of

Personality Disorders, 2nd Edition. Washington, DC, American Psychiatric Publishing (in

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Tusiani B, Tusiani PA, Tusiani-Eng P: Remnants of a Life on Paper. New York, Baroque

Press, 2013

Case 18.6 Painful Suicidality

Elizabeth L. Auchincloss, M.D.

Karmen Fuentes was a 50-year-old married Hispanic woman who presented to the

psychiatric emergency room (ER) at the urging of her outpatient psychiatrist after telling

him that she had been thinking about overdosing on Advil.

In the ER, Ms. Fuentes explained that her back had been “killing” her since she fell several

days earlier at the family-owned grocery store where she had worked for many years. The

fall had left her downcast and depressed, although she denied other depressive symptoms

aside from a poor mood. She spoke at length about the fall and about how it reminded her

of a fall that she had sustained a few years earlier. At that time, she had gone to see a

neurosurgeon, who told her to rest and take nonsteroidal anti-inflammatory drugs. She

described feeling “abandoned and not cared about” by him. The pain had diminished her

ability to exercise, and she was upset that she had gained weight. While relating the events

surrounding the fall, Ms. Fuentes began to cry.

When asked about her suicidal comments, she said they were “no big deal.” She reported

that they were “just a threat” aimed at her husband to “teach him a lesson” because “he has

no compassion for me” and had not been supportive since the fall. She insisted her

comments about overdosing did not have other meaning. When her ER interviewer

expressed concern about the possibility that she would kill herself, she exclaimed with a

smile, “Oh wow, I didn’t realize it’s so serious. I guess I shouldn’t do that again.” She then

shrugged and laughed. She went on to talk about how “nice and sweet” it was that so many

doctors and social workers wanted to hear her story, calling many of them by their first

names. She was also somewhat flirtatious with her male resident interviewer, who had

mentioned that she was the “best-dressed woman in the ER.”

According to her outpatient psychiatrist of 3 years, she had never before expressed suicidal

ideation until this week, and he would be unable to check in on her until after he left on

vacation the next day. Ms. Fuentes’s husband reported that she talked about suicide “like

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other people complain about the weather. She’s just trying to get me worried, but it doesn’t

work anymore.” He said he would never have suggested she go to the ER and thought the

psychiatrist had overreacted.

Ms. Fuentes initially sought outpatient psychotherapy at age 47 because she was feeling

depressed and unsupported by her husband. During 3 years of outpatient treatment, Ms.

Fuentes had been prescribed adequate trials of sertraline, escitalopram, fluoxetine, and

paroxetine. None seemed to help.

Ms. Fuentes described being “an early bloomer.” She became sexually active with older

men when she was in high school. She said dating had been the most fun thing she had ever

done and that she missed seeing men “jump through hoops” to sleep with her. She lived

with her 73-year-old husband. Her 25-year-old son lived nearby with his wife and young

son. She described her husband as a “very famous” musician. She said that he had never

helped around the house or with child-rearing and did not appreciate how much work she

put into taking care of their son and grandson.


Histrionic personality disorder


Ms. Fuentes presents to the ER with depression and suicidality, but neither of these

symptoms is as prominent as her ongoing pattern of excessive emotionality and attention

seeking. Her behavior with the ER staff and perhaps the fall itself appear to serve a need for

attention and care, and both Ms. Fuentes and her husband describe her chronic suicidal

threats as efforts to punish and elicit concern. For example, the ER visit was precipitated by

Ms. Fuentes making her first suicidal threat in treatment just as her doctor was going on

vacation, suggesting that she might have felt left out and abandoned.

Ms. Fuentes’s emotions shift rapidly between tearful and cheerful, but she consistently

dismisses the actual threat of suicide. Instead, Ms. Fuentes focuses on her dramatic fall,

and on her perception that neither her husband nor her neurosurgeon appears to be

interested in her suffering. Throughout her ER visit, she was seductive with her interviewer

and unusually friendly with staff, calling many of them by their first names. Even in a busy

ER, filled with sick, injured, and presumably unkempt people, Ms. Fuentes maintains her

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concern about her physical appearance. She implies that her dress, grooming, and weight

are centrally important to her sense of self-esteem, and that she continues to pay close

attention to their maintenance.

These observations suggest that her suicidality is not part of a major affective disorder.

Instead, she has at least six of the eight symptomatic criteria for a DSM-5 diagnosis of

histrionic personality disorder (HPD): discomfort when not the center of attention;

seductive behavior; intense but shifting and shallow emotionality; the use of physical

appearance to draw attention; self-dramatization and theatricality; and a tendency to

consider relationships to be more intimate than they are. While Ms. Fuentes does not show

clear evidence of other criteria for HPD, such as impressionistic speech and suggestibility,

these may have simply not been included in the case report.

Because patients with HPD often have comorbid somatic symptom disorders, careful

attention should be given to evaluating the patient for these disorders. Ms. Fuentes has

been episodically preoccupied with physical discomfort, and further evaluation might

demonstrate a more pervasive and impairing pattern of physical complaints or concerns.

Patients with HPD also have elevated rates of major depressive disorder. Indeed, Ms.

Fuentes shows many signs of depressed mood. Furthermore, Ms. Fuentes was referred to

the ER because of suicidality. Although she and her husband minimize the seriousness of

these threats, HPD does appear to be associated with an elevated risk of suicide attempts.

Many of these attempts will be sublethal, but a variety of suicidal “gestures” can lead to

serious harm and even semi-accidental death. Clinical work with Ms. Fuentes will involve

balancing the recognition that her suicidal ideation serves the need for attention with

awareness that it may also lead to actual self-harm.

As in all psychiatric assessments, clinicians must consider whether the personality issues

are a problem before making a diagnosis. Norms for emotional expressiveness,

interpersonal behavior, and style of dress vary significantly between cultures, genders, and

age groups, and it is important not to gratuitously pathologize variations that are not

accompanied by dysfunction and distress. As an example of potential bias, women are more

frequently diagnosed with HPD despite population studies that indicate that HPD is

equally common in men and women.

HPD is often comorbid with other personality disorders. Although Ms. Fuentes has traits

that are common to other personality disorders, she does not appear to have a second

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diagnosis. For example, Ms. Fuentes’s suicidal threats and dramatic presentation might

lead the examiner to consider borderline personality disorder. Ms. Fuentes does not,

however, show the marked instability in interpersonal relationships, extreme self-

destructiveness, angry disruptions in interpersonal relationships, and chronic feelings of

emptiness that are common in borderline personality disorder. While Ms. Fuentes

complains of not receiving the care that she would like, she does not manifest the fear of

separation and the sort of submissive and clingy behavior that are typical of dependent

personality disorder. Similarly, although she appears to have an excessive need for

admiration, she has not demonstrated the lack of empathy that is a cardinal feature of

narcissistic personality disorder. Finally, while she demonstrates some manipulative

behavior, as do people with antisocial personality disorder, hers is motivated by a desire for

attention rather than some sort of profit.

Suggested Readings

Gabbard GO: Cluster B personality disorders: hysterical and histrionic, in Psychodynamic

Psychiatry in Clinical Practice, 4th Edition. Washington, DC, American Psychiatric

Publishing, 2005, pp 541–570

Hales RE, Yudofsky SC, Roberts LW (eds): The American Psychiatric Publishing Textbook

of Psychiatry, 6th Edition. Washington, DC, American Psychiatric Publishing, 2014

MacKinnon RA, Michels R, Buckley PJ: The histrionic patient, in The Psychiatric

Interview in Clinical Practice, 2nd Edition. Washington, DC, American Psychiatric

Publishing, 2006, pp 137–176

Case 18.7 Dissatisfaction

Robert Michels, M.D.

Larry Goranov was a 57-year-old single unemployed white man who was asking for a

review of his treatment at the psychiatric clinic. He had been in weekly psychotherapy for 7

years with a diagnosis of dysthymic disorder. He complained that the treatment had been

of little help and he wanted to make sure that the doctors were on the right track.

Mr. Goranov reported a long-standing history of low-grade depressed mood and decreased

energy. He had to “drag” himself out of bed every morning and rarely looked forward to

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anything. He had lost his last job 3 years earlier, had broken up with a girlfriend slightly

later, and doubted that he would ever work or date again. He was embarrassed that he still

lived with his mother, who was in her 80s. He denied any immediate intention or plan to

kill himself, but if he did not improve by the time his mother died, he did not see what he

would have to live for. He denied disturbances in sleep, appetite, or concentration.

Clinic records indicated that Mr. Goranov had been adherent to adequate trials of

fluoxetine, escitalopram, sertraline, duloxetine, venlafaxine, and bupropion, as well as

augmentation with quetiapine, aripiprazole, lithium, and levothyroxine. He had some

improvement in his mood while taking escitalopram but did not have remission of

symptoms. He also had a course of cognitive-behavioral therapy early in his treatment; he

had been dismissive of the therapist and treatment, did not do his assigned homework, and

appeared to make no effort to use the therapy between sessions. He had never tried

psychodynamic psychotherapy.

Mr. Goranov expressed frustration at his lack of improvement, the nature of his treatment,

and his specific therapy. He found it “humiliating” that he was forced to see trainees who

rotated off his case every year or two. He frequently found that the psychiatry residents

were not especially educated, cultured, or sophisticated, and felt they knew less about

psychotherapy than he did. He much preferred to work with female therapists, because

men were “too competitive and envious.”

Mr. Goranov previously worked as an insurance broker. He explained, “It’s ridiculous. I

was the best broker they had ever seen, but they won’t rehire me. I think the problem is

that the profession is filled with big egos, and I can’t keep my mouth shut about it.” After

being “blackballed” by insurance agencies, Mr. Goranov did not work for 5 years, until he

was hired by an automobile dealer. He said that although it was beneath him to sell cars, he

was successful, and “in no time, I was running the place.” He quit within a few months after

an argument with the owner. Despite encouragement from several therapists, Mr. Goranov

had not applied for a job or pursued employment rehabilitation or volunteer work; he

strongly viewed these options as beneath him.

Mr. Goranov has “given up on women.” He had many partners as a younger man, but he

generally found them to be unappreciative and “only in it for the free meals.” The

psychiatric resident notes indicated that he responded to demonstrations of interest with

suspicion. This tendency held true in regard to both women who had tried to befriend him

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and residents who had taken an interest in his care. Mr. Goranov described himself as

someone who had a lot of love to give, but said that the world was full of manipulators. He

said he had a few buddies, but his mother was the only one he truly cared about. He

enjoyed fine restaurants and “five-star hotels,” but he added that he could no longer afford

them. He exercised daily and was concerned about maintaining his body. Most of his time

was spent at home watching television or reading novels and biographies.

On examination, the patient was neatly groomed, had slicked-back hair, and wore clothing

that appeared to be by a hip-hop designer generally favored by men in their 20s. He was

coherent, goal directed, and generally cooperative. He said he was sad and angry. His affect

was constricted and dismissive. He denied an intention to kill himself but felt hopeless and

thought of death fairly often. He was cognitively intact.


Narcissistic personality disorder


When a patient presents to a psychiatrist, symptoms are generally those aspects of

psychopathology that are easiest to recognize and to diagnose. Anxiety, depression,

obsessions, and phobias are seen similarly by patient and doctor and are central defining

characteristics of many disorders. Patients with personality disorders are different. Their

problems are often more distressing to others than to the patient, and their symptoms are

often vague and may seem secondary to their central issue. What determines the diagnosis

or defines the focus of treatment is not the anxiety or depression, for example, but rather

who the patient is, the life he or she has chosen to lead, and the pattern of his or her human


A corollary is that the patient’s complaints may be less revealing than the way in which they

are made. The consultation interview with most patients consists of collecting information

and making observations. The consultation with most patients who have personality

disorders requires the creation of a relationship, and then the doctor’s experiencing and

understanding of that relationship. Countertransference responses can be important

diagnostic tools, and the way in which the patient relates to the clinician reflects the

template that structures how the patient relates to others. For example, Mr. Goranov’s

primary complaint is his sad mood. Although he could have a depressive disorder, he seems

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to lack most of the pertinent DSM-5 criteria for any of the depressive disorders. Instead, his

low mood appears to be a response to chronic disappointment. Despite his view of himself

as talented and attractive, he is unemployed, underappreciated, and alone. Empty

demoralization is a common accompaniment to personality disorder and, as with Mr.

Goranov, is often unresponsive to pharmacotherapy.

Further, atypical for most patients with serious depression, he is concerned about

maintaining his appearance and his attractiveness to others. His grooming, clothes, and

manner reflect his underlying grandiosity, his conviction that he is special and deserving of

the appreciation that he has failed to receive.

This story about Mr. Goranov reflects a typical mild to moderate narcissistic personality

disorder. Classic features include grandiosity, a conviction that he deserves special

treatment, estrangement from others, a strikingly diminished capacity for empathy, and an

attitude of arrogant disdain. The depressed affect is clearly present, but it is secondary to

his fundamental personality psychopathology.

These patients are difficult to treat. They see their problem as the failure of the world to

recognize their true value, and they often slide into depressed, lonely social withdrawal as

life progresses. A therapeutic alliance requires making contact with them around their

pain, loneliness, and isolation, and working to enhance their pleasure rather than to

renounce their claims on others.

Mr. Goranov is a patient. He is not just someone with a social and personal identity who

happens to be a patient; being a patient has become central to who he is. Furthermore, he

is a dissatisfied patient, and his psychiatrist does not provide him with what he wants or

feels entitled to get. In fact, as his story unfolds, it is clear that this is a familiar problem for

Mr. Goranov. He is dissatisfied with his friends, his jobs, and his significant others. Like his

therapists, they have not been good enough, have failed to recognize his value, and have

failed him.

Suggested Readings

Akhtar S: The shy narcissist, in Changing Ideas in a Changing World: The Revolution in

Psychoanalysis. Essays in Honour of Arnold Cooper. Edited by Sandler J, Michels R,

Fonagy P. London, Karnac, 2000, pp 111–119

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Cooper AM: Further developments of the diagnosis of narcissistic personality disorder, in

Disorders of Narcissism: Diagnostic, Clinical, and Empirical Implications. Edited by

Ronningstam EF. Washington, DC, American Psychiatric Press, 1998, pp 53–74

Ronningstam EF (ed): Disorders of Narcissism: Diagnostic, Clinical, and Empirical

Implications. Washington, DC, American Psychiatric Press, 1998

Ronningstam EF, Weinberg I: Narcissistic personality disorder: progress in recognition

and treatment. Focus 11(2):167–177, 2013

Case 18.8 Shyness

J. Christopher Perry, M.P.H., M.D.

Mathilda Herbert was a 23-year-old woman referred for psychiatric consultation to help

her “break out of her shell.” She had recently moved to a new city to take classes to become

an industrial lab technician and had moved in with an older cousin, who was also a

psychotherapist and thought she should “get out and enjoy her youth.”

Although she had previously been prescribed medications for anxiety, Ms. Herbert said

that her real problem was “shyness.” School was difficult because everyone was constantly

“criticizing.” She avoided being called on in class because she knew she would “say

something stupid” and blush and everyone would make fun of her. She avoided speaking

up or talking on telephones, worried about how she would sound. She dreaded public


She was similarly reticent with friends. She said she had always been a people pleaser who

preferred to hide her feelings with a cheerful, compliant, attentive demeanor. She had a few

friends, whom she described as “warm and lifelong.” She felt lonely after her recent move

and had not yet met anyone from school or the local community.

She said she had broken up with her first serious boyfriend 2 years earlier. He had initially

been “kind and patient” and, through him, she had a social life by proxy. Soon after she

moved in with him, however, he turned out to be an “angry alcoholic.” She had not dated

since that experience.

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Ms. Herbert grew up in a metropolitan area with her parents and three older siblings. Her

brother was “hyperactive and antisocial” and took up everyone’s attention, whereas her

sisters were “hypercompetitive and perfect.” Her mother was anxiously compliant, “like

me.” Ms. Herbert’s father was a very successful investment manager who often pointed out

ways in which his children did not live up to his expectations. He could be supportive but

tended to disregard emotional uncertainty in favor of a “tough optimism.” Teasing and

competition “saturated” the household, and “it didn’t help that I was forced to go to the

same girls’ school where my sisters had been stars and where everyone was rich and catty.”

She developed a keen sensitivity to criticism and failure.

Her parents divorced during her senior year of high school. Her father married another

woman soon thereafter. Although she had planned to attend the same elite university as

her two sisters, she chose to attend a local community college at the last minute. She

explained that it was good to be away from all the competition, and her mother needed the


Ms. Herbert’s strengths included excellent work in her major, chemistry, especially after

one senior professor took a special interest. Family camping trips had led to a mastery of

outdoor skills, and she found that she enjoyed being out in the woods, flexing her

independence. She also enjoyed babysitting and volunteering in animal shelters, because

kids and animals “appreciate everything you do and aren’t mean.”

During the evaluation, Ms. Herbert was a well-dressed young woman of short stature who

was attentive, coherent, and goal directed. She smiled a lot, especially when talking about

things that would have made most people angry. When the psychiatrist offered a trial

comment, linking Ms. Herbert’s current anxiety to experiences with her father, the patient

appeared quietly upset. After several such instances, the psychiatrist worried that any

interpretive comments might be taken as criticism and had to check a tendency to avoid

sensitive subjects. Explicitly discussing his concerns led both the patient and psychiatrist to

relax and allowed the conversation to continue more productively.


Avoidant personality disorder

Social anxiety disorder

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Ms. Herbert’s shyness extends into a persistent social avoidance that reduces her ability to

enjoy herself. She underperforms at school, and she seems to have chosen her college (a

local community college) and career (lab technician) largely to reduce perceived risk and to

avoid anxiety. She feels lonely but is unable to make connections with friends. She is

stymied in her efforts to date men. She appears to have two DSM-5 diagnoses that are so

often comorbid that they may be differing conceptualizations of similar conditions:

avoidant personality disorder (AvPD) and social anxiety disorder (social phobia).

AvPD reflects a persistent pattern of social inhibition, feelings of inadequacy, and

hypersensitivity to negative evaluation. It also requires four or more of seven criteria,

which Ms. Herbert easily meets. She avoids occupational activities that involve significant

interpersonal contact. For most of her life, she has been reluctant to speak up, fearing to

draw criticism or ridicule, even from family members. She avoids being the center of

attention, is self-doubting, and blushes easily. She avoids new situations. She is unwilling

to get involved with people unless she is certain that she will be liked. These have had a

debilitating effect on all aspects of her life.

Like most people with AvPD, Ms. Herbert also qualifies for DSM-5 social anxiety disorder

(social phobia). She demonstrates fear of social scrutiny and of being negatively evaluated.

Social situations are endured, but barely, and her anxiety is almost always present. She

appears shy, selects work where there will be limited social interaction, and prefers to live

with family members.

Ms. Herbert describes having these symptoms from a young age. Although shyness is

commonly reported in individuals with AvPD and social anxiety disorder, most shy

children do not go on to report the sorts of issues prevalent in people with these disorders:

diminished school performance, employment, productivity, socioeconomic status, quality

of life, and overall well-being.

During the interview, the psychiatrist sensed Ms. Herbert’s distress and felt

uncharacteristically restricted in what he could ask. In other words, he became aware of a

countertransference reaction in which he feared hurting her feelings. After he shared his

own concerns that she would feel criticized by his comments, both the psychiatrist and the

patient were able to more comfortably explore her history and deepen the therapeutic

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alliance. A strong alliance helps mitigate distress and shame and increases the likelihood of

a more thorough exploration for common comorbidities as well as a smoother transition

into treatment.

Suggested Readings

Perry JC: Cluster C personality disorders: avoidant, obsessive-compulsive, and

dependent, in Gabbard’s Treatments of Psychiatric Disorders, 5th Edition. Edited by

Gabbard GO. Washington, DC, American Psychiatric Publishing (in press)

Sanislow CA, Bartolini EE, Zoloth EC: Avoidant personality disorder, in Encyclopedia of

Human Behavior, 2nd Edition. Edited by Ramachandran VS. San Diego, CA, Academic

Press, 2012, pp 257–266

Case 18.9 Lack of Self-Con�dence

Raymond Raad, M.D., M.P.H.

Paul S. Appelbaum, M.D.

Nate Irvin was a 31-year-old white man who sought outpatient psychiatric services for “lack

of self-confidence.” He reported lifelong troubles with assertiveness and was specifically

upset by having been “stuck” for 2 years at his current “dead-end” job as an administrative

assistant. He wished someone would tell him where to go next so that he would not have to

face the “burden” of decision. At work, he found it easy to follow his boss’s directions but

had difficulty making even minor independent decisions. The situation was “depressing,”

he said, but nothing new.

Mr. Irvin also reported dissatisfaction with his relationships with women. He described a

series of several-month-long relationships over the prior 10 years that ended despite his

doing “everything I could.” His most recent relationship had been with an opera singer. He

reported having gone to several operas and taken singing classes to impress her, even

though he did not particularly enjoy music. That relationship had recently ended for

unclear reasons. He said his mood and self-confidence were tied to his dating. Being single

made him feel desperate, but desperation made it even harder to get a girlfriend. He said he

felt trapped by that spiral. Since the latest breakup, he had been quite sad, with frequent

crying spells. It was this depression that had prompted him to seek treatment. He denied

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all other symptoms of depression, including problems with sleep, appetite, energy,

suicidality, and ability to enjoy things.

Mr. Irvin initially denied taking any medications, but he eventually revealed that 1 year

earlier his primary care physician had begun to prescribe alprazolam 0.5 mg/day for

“anxiety.” His dose had escalated, and at the time of the evaluation, Mr. Irvin was taking 5

mg/day and getting prescriptions from three different physicians. Cutting back led to

anxiety and “the shakes.”

Mr. Irvin denied any prior personal or family psychiatric history, including outpatient

psychiatric appointments.

After hearing this history, the psychiatrist was concerned about Mr. Irvin’s escalating

alprazolam use and his chronic difficulties with independence. She thought the most

accurate diagnosis was benzodiazepine use disorder comorbid with a personality disorder.

However, she was concerned about the negative unintended effects that these diagnoses

might have on the patient, including his employment and insurance coverage, as well as

how he would be dealt with by future clinicians. She typed into the electronic medical

record a diagnosis of “adjustment disorder with depressed mood.” Two weeks later, Mr.

Irvin’s insurance company asked her his diagnosis, and she gave the same diagnosis.


Dependent personality disorder

Benzodiazepine use disorder


Mr. Irvin has an excessive need for someone to take care of him and make decisions for

him. He has difficulty making decisions independently and wishes that others would make

them for him. He lacks the confidence to initiate projects or do things on his own, he

generally feels uncomfortable being alone, and he is reluctant to disagree on even minor

matters. He goes to almost desperate lengths to seek and maintain relationships and to

obtain support and nurturing from others.

Mr. Irvin, therefore, meets at least six of the eight DSM-5 criteria (only five are required)

for dependent personality disorder. To meet the criteria for the diagnosis, these patterns

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must also fit the general criteria for a personality disorder (i.e., the symptoms must differ

from cultural expectations and be enduring, inflexible, pervasive, and associated with

distress and/or impairment in functioning). Mr. Irvin’s symptoms meet this standard.

Furthermore, his symptoms are persistent and debilitating, and lie outside the normal

expectations for a healthy adult man of his age.

Many psychiatric diagnoses can intensify dependent personality traits or be comorbid with

dependent personality disorder. In this patient, it is especially important to consider a

mood disorder, because he presents with “depression” that has recently worsened. Some

patients with mood disorders can present with symptoms that mimic personality disorders,

so if this patient is in the midst of a major depressive episode, his dependent symptoms

may be confined to that episode. Mr. Irvin, however, denies other symptoms of depression

and does not meet criteria for any of the depressive disorders.

Notably, Mr. Irvin is using alprazolam. He has been taking the medication in increasing

amounts over a longer period of time than was intended. To obtain an adequate supply, he

gets prescriptions from three different physicians. He has developed tolerance (resulting in

dose escalation) and withdrawal (as demonstrated by anxiety and shakes). Assuming that

further exploration would confirm clinically significant impairment or distress, Mr. Irvin

meets criteria for a benzodiazepine use disorder. Given his history of use and his tendency

not to be entirely transparent, it would be especially important to tactfully explore the

possibility that he is using other substances, including alcohol, tobacco, illicit drugs, and

prescription drugs such as opioids.

The psychiatrist in this case faces a conflict common in clinical practice. Documentation of

patients’ diagnoses in clinical charts—and their release to third parties—can sometimes

have downstream effects on patients’ insurance coverage or disability status and can lead to

stigmatization, both within and outside the health care system. Given this reality,

psychiatrists can be tempted to record only the least severe of several diagnoses, or

sometimes to report inaccurate but presumably less pejorative disorders. In this case, the

psychiatrist does both. Although the patient has depressed mood, he does not meet criteria

for the adjustment disorder that is recorded by his psychiatrist. He does, however, appear

to meet criteria for both dependent personality disorder and benzodiazepine use disorder,

but neither of these more serious and potentially more stigmatizing diagnoses is included

in the chart or disclosed to the insurer.

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When diagnoses are inaccurately recorded in medical charts, ostensibly for the purpose of

protecting patients, this may end up causing harm instead. Subsequent clinicians who

review the records may lack critical information regarding patients’ presentation and

treatment. For example, if Mr. Irvin were to urgently call for a prescription of

benzodiazepines, a covering psychiatrist might have no way of knowing from the patient’s

chart about either the pattern of benzodiazepine abuse or the physiological dependence. As

a physician who intends to “do no harm,” Mr. Irvin’s psychiatrist has tried to shield him

from stigma but has instead exposed him to medical risk.

The physician has other responsibilities beyond those to the patient. When the physician

and patient agree to accept payment from an insurer, the physician may be obligated to

provide to insurers and governmental agencies a reasonable amount of honest clinical

information. Lack of disclosure is tantamount to fraud and can be prosecuted. In addition,

although being part of the medical profession affords many privileges, it also involves

responsibilities. Diagnostic deceit may seem like an innocuous effort to protect the patient,

but the dishonesty negatively affects the reputation of the entire profession, a reputation

that is integral to the ability to render treatment to future patients.

Suggested Readings

Appelbaum PS: Privacy in psychiatric treatment: threats and responses. Am J Psychiatry

159(11):1809–1818, 2002 PubMed ID: 12411211

Howe E: Core ethical questions: what do you do when your obligations as a psychiatrist

conflict with ethics? Psychiatry 7(5):19–26, 2010 PubMed ID: 20532154

Mullins-Sweatt SN, Bernstein DP, Widiger TA: Retention or deletion of personality

disorder diagnoses for DSM-5: an expert consensus approach. J Pers Disord 26(5):689–

703, 2012 PubMed ID: 23013338

Case 18.10 Relationship Control

Michael F. Walton, M.D.

Ogden Judd and his boyfriend, Peter Kleinman, presented for couples therapy to address

escalating conflict around the issue of moving in together. Mr. Kleinman described a

several-month-long apartment search that was made “agonizing” by Mr. Judd’s rigid work

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schedule and his “endless” list of apartment demands. They were unable to come to a

decision, and eventually they decided to just share Mr. Judd’s apartment. As Mr. Kleinman

concluded, “Ogden won.”

Mr. Judd refused to hire movers for his boyfriend’s belongings, insisting on personally

packing and taking an inventory of every item in his boyfriend’s place. What should have

taken 2 days took 1 week. Once the items were transported to Mr. Judd’s apartment, Mr.

Kleinman began to complain about Mr. Judd’s “crazy rules” about where items could be

placed on the bookshelf, which direction the hangers in the closet faced, and whether their

clothes could be intermingled. Moreover, Mr. Kleinman complained that there was hardly

any space for his possessions because Mr. Judd never threw anything away. “I’m terrified of

losing something important,” added Mr. Judd.

Over the ensuing weeks, arguments broke out nightly as they unpacked boxes and settled

in. Making matters worse, Mr. Judd would often come home after 9:00 or 10:00 p.m.,

because he had a personal rule to always have a blank “to-do” list by the end of the day. Mr.

Kleinman would often wake early in the morning to find Mr. Judd grimly organizing

shelves or closets or sorting books alphabetically by author. Throughout this process, Mr.

Judd appeared to be working hard at everything while enjoying himself less and getting less

done. Mr. Kleinman found himself feeling increasingly detached from his boyfriend the

longer they lived together.

Mr. Judd denied symptoms of depression and free-floating anxiety. He said that he had

never experimented with cigarettes or alcohol, adding, “I wouldn’t want to feel like I was

out of control.” He denied a family history of mental illness. He was raised in a two-parent

household and was an above average high school and college student. He was an only child

and first shared a room as a college freshman. He described that experience as being

difficult due to “conflicting styles—he was a mess and I knew that things should be kept

neat.” He had moved mid-year into a single dorm room and had not lived with anyone until

Mr. Kleinman moved in. Mr. Judd was well liked by his boss, earning recognition as

“employee of the month” three times in 2 years. Feedback from colleagues and

subordinates was less enthusiastic, indicating that he was overly rigid, perfectionistic, and


On examination, Mr. Judd was a thin man with eyeglasses and gelled hair, sitting on a

couch next to his boyfriend. He was meticulously dressed. He was cooperative with the

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interview and sat quietly while his boyfriend spoke, interrupting on a few occasions to

contradict. His speech was normal in rate and tone. His affect was irritable. There was no

evidence of depression. He denied specific phobias and did not think he had ever

experienced a panic attack. At the end of the consultation, Mr. Judd remarked, “I know I’m

difficult, but I really do want this to work out.”


Obsessive-compulsive personality disorder


Couples treatment would probably focus on the relationship rather than on either of the

two men, but the case report clearly focuses on Mr. Judd’s contribution to the difficulties in

the relationship. Mr. Judd is viewed as a controlling, perfection-driven, and inflexible

“workaholic.” He holds on to belongings excessively and finds it difficult to integrate new

items into his apartment, spending hours single-handedly organizing books that could

otherwise just be placed on a bookshelf. He is driven and unable to delegate, and although

those qualities can be adaptive in some circumstances, they are causing him distress and

dysfunction in regard to his situation with his boyfriend and with his colleagues at work.

Mr. Judd appears to fulfill criteria, therefore, for a DSM-5 diagnosis of obsessive-

compulsive personality disorder (OCPD).

OCPD and obsessive-compulsive disorder (OCD) can be comorbid, but the two conditions

usually exist separately. The important distinguishing factor is that whereas OCPD is

considered a maladaptive pattern of behavior marked by excessive control and inflexibility,

OCD is characterized by the presence of true obsessions and compulsions.

There can, however, be significant behavioral overlap between OCD and OCPD. For

example, hoarding behaviors can be common to both diagnoses. In OCPD, the cause of the

hoarding disorder is the need for order and completeness, and Mr. Judd reports that he is

“terrified of losing something important.” To compensate for the fact that his apartment is

now shared with his boyfriend—and is overfull—Mr. Judd works grimly into the night so

that his bookshelves and closet maintain their usual standard of excessive organization. In

OCD, the cause of the hoarding tends to be either the avoidance of onerous compulsive

rituals or obsessional and often irrational fears of incompleteness, harm, and

contamination. The behaviors are typically unwanted and distressing, and are likely to lead

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to the accumulation of odd debris such as fingernail clippings or rotten food. In hoarding

disorder, a new diagnosis in DSM-5, the focus is exclusively on a persistent difficulty

discarding or parting with possessions rather than on a need for order or on obsessions and


In regard to Mr. Judd, it would be useful to specifically explore whether his hoarding

behavior attenuates a specific, particularly distressing or intrusive thought, and to

understand the extent of his accumulations. His list-making and arranging may be

compulsions and meet criteria for OCD if they are found not only to be accompanied by

tension and difficulty relaxing but also to be time-consuming, distressing, overly repetitive,

and ritualistic. Although DSM-5 encourages an effort to distinguish between OCPD, OCD,

and hoarding disorder, these three disorders can be comorbid with each other.

As discussed in the introduction to this chapter, Section III of DSM-5 outlines an

alternative model that includes five personality disorder trait domains (see Table 18- in the

introduction to this chapter): negative affectivity, detachment, antagonism, disinhibition

(vs. conscientiousness), and psychoticism. Several of these factors are pertinent to a

diagnosis of OCPD. For example, Mr. Judd’s interpersonal style with both his boyfriend

and his coworkers appears to be marked by rigid detachment and restricted levels of

intimacy. He manifests significant amounts of negative affectivity, as reflected in his grim

persistence in continuing tasks past the point of usefulness. Finally, Mr. Judd’s

compulsivity pervades the entire story, as marked by extreme conscientiousness and rigid


Suggested Readings

Hays P: Determination of the obsessional personality. Am J Psychiatry 129(2):217–219,

1972 PubMed ID: 5041064

Lochner C, Serebro P, van der Merwe L, et al: Comorbid obsessive-compulsive personality

disorder in obsessive-compulsive disorder (OCD): a marker of severity. Prog

Neuropsychopharmacol Biol Psychiatry 35(4):1087–1092, 2011 PubMed ID: 21411045

Pinto MA, Eisen J, Mancebo M, et al: Obsessive-compulsive personality disorder, in

Obsessive-Compulsive Disorder: Subtypes and Spectrum Conditions. Edited by

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Abramowitz J, McKay D, Taylor S. Oxford, UK, Oxford University Press, 2008, pp 246–


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