Prescription medication is widely used to treat children with attention-deficit/hyperactivity disorder (ADHD). In some cases, medication can be highly effective and allow individuals to function normally in their daily life tasks. Critics argue that alternative methods and therapies should be used before turning to medication. Review some of the considerations of medication use in the following article:
National Resource Center on ADHD. (2015). Managing medication for children and adolescents with ADHD. https://chadd.org/wp-content/uploads/2018/05/managing_medication.pdf
Answer the following questions:
Discuss at least one advantage and one disadvantage of the use of medication in the treatment of ADHD.
Considerable research has been conducted on non-medication treatment approaches for illnesses like ADHD. For example, the following article examines a change in diet and nutrition as treatment.
Stobernack, T., de Vries, S. P. W., Rodrigues Pereira, R., Pelsser, L. M., Ter Braak, C. J. F., Aarts, E., van Baarlen, P., Kleerebezem, M., Frankena, K., & Hontelez, S. (2019). Biomarker research in ADHD: The impact of nutrition (BRAIN) – study protocol of an open-label trial to investigate the mechanisms underlying the effects of a few-foods diet on ADHD symptoms in children. BMJ Open, 9(11). https://doi-org.libauth.purdueglobal.edu/10.1136/bmjopen-2019-029422
Discuss possible alternative treatment approaches to ADHD (non-medication). Do you feel that these should be considered before medication is prescribed?
A thorough answer will be 250–350 words in length.
The neurocognitive disorders (NCDs) begin with delirium, followed by the syndromes of major NCD, mild NCD, and their etiological subtypes. The major or mild NCD subtypes are NCD due to Alzheimer’s disease; vascular NCD; NCD with Lewy bodies; NCD due to Parkinson’s disease; frontotemporal NCD; NCD due to traumatic brain injury; NCD due to HIV infection; substance/medication-induced NCD; NCD due to Huntington’s disease; NCD due to prion disease; NCD due to another medical condition; NCD due to multiple etiologies; and NCD due to unknown etiology. The NCD category encompasses the group of disorders in which the primary clinical deficit is in cognitive function, and that are acquired rather than developmental. Although cognitive deficits are present in many if not all mental disorders (e.g., schizophrenia, bipolar disorders), only disorders whose core features are cognitive are included in the NCD category. The NCDs are those in which impaired cognition has not been present since birth or very early life, and thus represents a decline from a previously attained level of functioning.
The NCDs are unique among DSM-5 categories in that these are syndromes for which the underlying pathology, and frequently the etiology as well, can potentially be determined. The various underlying disease entities have all been the subject of extensive research, clinical experience, and expert consensus on diagnostic criteria. The DSM-5 criteria for these disorders have been developed in close consultation with the expert groups for each of the disease entities and align as closely as possible with the current consensus criteria for each of them. The potential utility of biomarkers is also discussed in relation to diagnosis. Dementia is subsumed under the newly named entity major neurocognitive disorder, although the term dementia is not precluded from use in the etiological subtypes in which that term is standard. Furthermore, DSM-5 recognizes a less severe level of cognitive impairment, mild neurocognitive disorder, which can also be a focus of care. Diagnostic criteria are provided for both these syndromic entities, followed by diagnostic criteria for the different etiological subtypes. Several of the NCDs frequently coexist with one another, and their relationships may be multiply characterized under different chapter subheadings, including “Differential Diagnosis” (e.g., NCD due to Alzheimer’s disease vs. vascular NCD), “Risk and Prognostic Factors” (e.g., vascular pathology increasing the clinical expression of Alzheimer’s disease), or “Comorbidity” (e.g., mixed Alzheimer’s disease–vascular pathology).
The term dementia is retained in DSM-5 for continuity and may be used in settings where physicians and patients are accustomed to this term. Although dementia is the customary term for disorders like the degenerative dementias that usually affect older adults, the term neurocognitive disorder is widely used and often preferred for conditions affecting younger individuals, such as impairment secondary to traumatic brain injury or HIV infection. Furthermore, the major NCD definition is somewhat broader than the term dementia, in that a diagnosis of major NCD can be made if there is a significant cognitive decline in only one cognitive domain, whereas a diagnosis of dementia in ICD-10 and ICD-11 (and formerly in DSM-IV) requires multiple cognitive deficits. Thus, cases that would qualify in ICD-10 and ICD-11 (and formerly DSM-IV) for a diagnosis of amnestic disorder (memory impairment in the absence of other cognitive deficits) are diagnosed as major NCD in DSM-5.
For major and mild NCDs, the diagnostic criteria for several of the etiological subtypes allow for the designation of the degree of certainty regarding the possible presence of the medical conditions, as well the strength of the causal connection between the medical condition and the NCD. For NCD due to Alzheimer’s disease, frontotemporal NCD, and NCD with Lewy bodies, establishing whether these medical conditions are present in the individual can be extremely challenging, and sometimes the etiology can only be firmly established postmortem; for these subtypes, the probable/possible designation precedes the name of the medical condition (e.g., mild NCD due to possible Alzheimer’s disease, major NCD due to probable frontotemporal degeneration). Because the diagnostic criteria for vascular NCD and NCD due to Parkinson’s disease require clear evidence of the presence of vascular disease or Parkinson’s disease, respectively, for those subtypes the uncertainty is about the causal connection between the medical condition and the NCD. For those subtypes, the designations “probably due to” and “possibly due to” apply.
The criteria for the various NCDs are based on defined cognitive domains. 1 provides for each of the key domains a working definition, examples of symptoms or observations regarding impairments in everyday activities, and examples of assessments. The domains thus defined, along with guidelines for clinical thresholds, form the basis on which the NCDs, their levels, and their subtypes may be diagnosed.
A disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) accompanied by reduced awareness of the environment.
The disturbance develops over a short period of time (usually hours to a few days), represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day.
An additional disturbance in cognition (e.g., memory deficit, disorientation, language, visuospatial ability, or perception).
The disturbances in Criteria A and C are not better explained by another preexisting, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal, such as coma.
There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal (i.e., due to a drug of abuse or to a medication), or exposure to a toxin, or is due to multiple etiologies.
Acute: Lasting a few hours or days.
Persistent: Lasting weeks or months.
Hyperactive: The individual has a hyperactive level of psychomotor activity that may be accompanied by mood lability, agitation, and/or refusal to cooperate with medical care.
Hypoactive: The individual has a hypoactive level of psychomotor activity that may be accompanied by sluggishness and lethargy that approaches stupor.
Mixed level of activity: The individual has a normal level of psychomotor activity even though attention and awareness are disturbed. Also includes individuals whose activity level rapidly fluctuates.
Substance intoxication delirium: This diagnosis should be made instead of substance intoxication when the symptoms in Criteria A and C predominate in the clinical picture and when they are sufficiently severe to warrant clinical attention.
Coding note: The ICD-10-CM codes for the [specific substance] intoxication delirium are indicated in the table below. Note that the ICD-10-CM code depends on whether or not there is a comorbid substance use disorder present for the same class of substance. If a mild substance use disorder is comorbid with the substance intoxication delirium, the 4th position character is “1,” and the clinician should record “mild [substance] use disorder” before the substance intoxication delirium (e.g., “mild cocaine use disorder with cocaine intoxication delirium”). If a moderate or severe substance use disorder is comorbid with the substance intoxication delirium, the 4th position character is “2,” and the clinician should record “moderate [substance] use disorder” or “severe [substance] use disorder,” depending on the severity of the comorbid substance use disorder. If there is no comorbid substance use disorder (e.g., after a one-time heavy use of the substance), then the 4th position character is “9,” and the clinician should record only the substance intoxication delirium.
Substance withdrawal delirium: This diagnosis should be made instead of substance withdrawal when the symptoms in Criteria A and C predominate in the clinical picture and when they are sufficiently severe to warrant clinical attention.
Coding note: The ICD-10-CM codes for the [specific substance] withdrawal delirium are indicated in the table below. Note that the ICD-10-CM code depends on whether or not there is a comorbid substance use disorder present for the same class of substance. If a mild substance use disorder is comorbid with the substance withdrawal delirium, the 4th position character is “1,” and the clinician should record “mild [substance] use disorder” before the substance withdrawal delirium (e.g., “mild alcohol use disorder with alcohol withdrawal delirium”). If a moderate or severe substance use disorder is comorbid with the substance withdrawal delirium, the 4th position character is “2,” and the clinician should record “moderate [substance] use disorder” or “severe [substance] use disorder,” depending on the severity of the comorbid substance use disorder. If there is no comorbid substance use disorder (e.g., after regular use of an anxiolytic substance taken as prescribed), then the 4th position character is “9,” and the clinician should record only the substance withdrawal delirium.
Medication-induced delirium: This diagnosis applies when the symptoms in Criteria A and C arise as a side effect of a medication taken as prescribed.
Code [specific medication]–induced delirium: F11.921 opioid taken as prescribed (or F11.988 if during withdrawal from opioid taken as prescribed); F12.921 pharmaceutical cannabis receptor agonist taken as prescribed; F13.921 sedative, hypnotic, or anxiolytic taken as prescribed (or F13.931 if during withdrawal from sedative, hypnotic, or anxiolytic taken as prescribed); F15.921 amphetamine-type substance or other stimulant taken as prescribed; F16.921 ketamine or other hallucinogen taken as prescribed or for medical reasons; F19.921 for medications that do not fit into any of the classes (e.g., dexamethasone) and in cases in which a substance is judged to be an etiological factor but the specific class of substance is unknown (or F19.931 if during withdrawal from medications that do not fit into any of the classes, taken as prescribed).
(F05) Delirium due to another medical condition: There is evidence from the history, physical examination, or laboratory findings that the disturbance is attributable to the physiological consequences of another medical condition.
Coding note: Include the name of the other medical condition in the name of the delirium (e.g., F05 delirium due to hepatic encephalopathy). The other medical condition should also be coded and listed separately immediately before the delirium due to another medical condition (e.g., K76.82 hepatic encephalopathy; F05 delirium due to hepatic encephalopathy).
(F05) Delirium due to multiple etiologies: There is evidence from the history, physical examination, or laboratory findings that the delirium has more than one etiology (e.g., more than one etiological medical condition; another medical condition plus substance intoxication or medication side effect).
Coding note: Use multiple separate codes reflecting specific delirium etiologies (e.g., K76.82 hepatic encephalopathy; F05 delirium due to hepatic failure; F10.231 severe alcohol use disorder with alcohol withdrawal delirium). Note that the etiological medical condition both appears as a separate code that precedes the delirium code and is substituted into the delirium due to another medical condition rubric.
Substance intoxication delirium
The name of the substance intoxication delirium begins with the specific substance (e.g., cocaine) that is presumed to be causing the delirium. The diagnostic code is selected from the table included in the criteria set, which is based on the drug class and presence or absence of a comorbid substance use disorder. For substances that do not fit into any of the classes (e.g., dexamethasone), the code for “other substance” should be used; and in cases in which a substance is judged to be an etiological factor but the specific class of substance is unknown, the category “unknown substance” should be used.
When recording the name of the disorder, the comorbid substance use disorder (if any) is listed first, followed by the word “with,” followed by the name of the substance intoxication delirium, followed by the course (i.e., acute, persistent), followed by the specifier indicating level of psychomotor activity (i.e., hyperactive, hypoactive, mixed level of activity). For example, in the case of acute hyperactive intoxication delirium occurring in a man with a severe cocaine use disorder, the diagnosis is F14.221 severe cocaine use disorder with cocaine intoxication delirium, acute, hyperactive. A separate diagnosis of the comorbid severe cocaine use disorder is not given. If the intoxication delirium occurs without a comorbid substance use disorder (e.g., after a one-time heavy use of the substance), no accompanying substance use disorder is noted (e.g., F16.921 phencyclidine intoxication delirium, acute, hypoactive).
Substance withdrawal delirium
The name of the substance withdrawal delirium begins with the specific substance (e.g., alcohol) that is presumed to be causing the withdrawal delirium. The diagnostic code is selected from substance-specific codes in the coding note included in the criteria set. When recording the name of the disorder, the comorbid substance use disorder (if any) is listed first, followed by the word “with,” followed by the substance withdrawal delirium, followed by the course (i.e., acute, persistent), followed by the specifier indicating level of psychomotor activity (i.e., hyperactive, hypoactive, mixed level of activity). For example, in the case of acute hyperactive withdrawal delirium occurring in a man with a severe alcohol use disorder, the diagnosis is F10.231 severe alcohol use disorder with alcohol withdrawal delirium, acute, hyperactive. A separate diagnosis of the comorbid severe alcohol use disorder is not given.
The name of the medication-induced delirium begins with the specific substance (e.g., dexamethasone) that is presumed to be causing the delirium. The name of the disorder is followed by the course (i.e., acute, persistent), followed by the specifier indicating level of psychomotor activity (i.e., hyperactive, hypoactive, mixed level of activity). For example, in the case of acute hyperactive medication-induced delirium occurring in a man using dexamethasone as prescribed, the diagnosis is F19.921 dexamethasone-induced delirium, acute, hyperactive.
Regarding course, in hospital settings, delirium usually lasts about 1 week, but some symptoms often persist even after individuals are discharged from the hospital.
Individuals with delirium may rapidly switch between hyperactive and hypoactive states. The hyperactive state may be more common or more frequently recognized(Morandi et al. 2017) and often is associated with medication side effects and drug withdrawal. The hypoactive state may be more frequent in older adults and is often unrecognized among older individuals in emergency departments and hospitals(Han et al. 2009; Meagher et al. 2014).
The essential feature of delirium is an acute impairment of consciousness characterized by a disturbance in attention accompanied by reduced awareness of the environment, both core features of normal consciousness. Because these deficits reflect an altered state of consciousness affecting many higher cerebral cortical functions of the cerebral cortex, they are accompanied by a change from baseline in other cognitive functions that cannot be better explained by a preexisting or evolving neurocognitive disorder (NCD). The disturbance in attention (Criterion A) is manifested by reduced ability to direct, focus, sustain, and shift attention. Questions must be repeated because the individual’s attention wanders, or the individual may perseverate with an answer to a previous question rather than appropriately shift attention. The individual is easily distracted by irrelevant stimuli. The disturbance in awareness affects both internal thinking and insight as well as difficulty making sense of what is happening in the external environment(Choi et al. 2012).
The disturbance develops over a short period of time, usually hours to a few days, and tends to fluctuate during the course of the day, often with worsening in the evening and night when external orienting stimuli decrease (Criterion B). There is evidence from the history, physical examination, or laboratory findings that the disturbance is a physiological consequence of an underlying medical condition, substance intoxication or withdrawal, use of a medication, or a toxin exposure, or a combination of these factors (Criterion E). The etiology should be coded according to the etiologically appropriate subtype (i.e., substance or medication intoxication, substance withdrawal, another medical condition, or multiple etiologies). Delirium often occurs in the context of an underlying NCD(Fong et al. 2015). The impaired brain function of individuals with mild and major NCD renders them more vulnerable to developing a delirium.
There is an accompanying change in at least one other area that may include memory and learning (particularly recent memory), disorientation (particularly to time and place), alteration in language (particularly semantic comprehension), or perceptual distortion or a perceptual-motor disturbance (Criterion C). The perceptual disturbances accompanying delirium include misinterpretations, illusions, or hallucinations; these disturbances are typically visual, but may occur in other modalities as well, and range from simple and uniform to highly complex.
Normal attention/arousal, delirium, and coma lie on a continuum. Coma is defined as a state of unconsciousness with an absence of cognition or sleep-wake cycle, along with the lack of any meaningful response to verbal or physical stimuli. Delirium is an impaired state of consciousness in the setting of an aroused cortex. The ability to evaluate cognition to diagnose delirium depends on there being a level of cortical arousal and wakefulness sufficient for response to verbal stimulation; hence, delirium should not be diagnosed in the context of coma (Criterion D). Stuporous individuals also have a reduced level of brain arousal, but not to the extent of the complete unconsciousness of coma. Coma and stupor can be due to neurological conditions or drug-induced as with iatrogenic deep sedation in intensive care unit (ICU) settings or general anesthesia. Those individuals who show only minimal responses to verbal or physical stimulation are incapable of engaging with attempts at standardized testing or even interview. This inability to engage should be classified as a disorder of arousal such as coma or stupor, and not as delirium(Eapen et al. 2017). However, delirium can be a stage that follows emergence from coma or stupor, especially when coma is the result of a neurological condition. Further, the sleep-wake cycle disturbance characteristic of the circadian rhythm disturbance in delirium can interfere with full assessment of the individual if in a sleep phase, which should be distinguished from a disorder of brain arousal(Maas et al. 2020).
Delirium is often associated with a disturbance in the sleep-wake cycle. This disturbance can include daytime sleepiness, nighttime agitation, difficulty falling asleep, excessive sleepiness throughout the day, or wakefulness throughout the night. In some cases, complete reversal of the night-day sleep-wake cycle can occur. Sleep-wake cycle disturbances are very common in delirium and have been proposed as a core criterion for the diagnosis(Fitzgerald et al. 2013; Fitzgerald et al. 2017; Franco et al. 2013).
The individual with delirium may exhibit emotional disturbances, such as anxiety, fear, depression, irritability, anger, euphoria, and apathy(Fitzgerald et al. 2013; Fitzgerald et al. 2017). There may be rapid and unpredictable shifts from one emotional state to another. The disturbed emotional state may also be evident in calling out, screaming, cursing, muttering, moaning, or making other sounds. These behaviors are especially prevalent at night and under conditions in which stimulation and environmental cues are lacking.
The prevalence of delirium is highest among hospitalized older individuals and varies depending on the individuals’ characteristics, setting of care, and sensitivity of the detection method. Data from the United States and Finland indicate that the prevalence of delirium in the community overall is low (1%–2%)(Inouye 2006; Inouye et al. 2014). The prevalence is 8%–17% in older individuals presenting to North American emergency departments, where the delirium often indicates a medical illness(Inouye et al. 2014).
Based on data from various countries, the prevalence of delirium when individuals are admitted to the hospital ranges from 18% to 35%, and estimates of the occurrence of delirium arising during hospitalization range from 29% to 64% in general hospital populations(Agostino and Inouye 2003; Inouye et al. 2014). Internationally, delirium occurs in 11%–51% of older individuals postoperatively(Inouye et al. 2014) and in up to 81% of those in intensive care(Zaal et al. 2015). The prevalence of delirium ranges from 20% to 22% in individuals in nursing homes or post–acute care settings(Inouye et al. 2014) and occurs in up to 88% of individuals with terminal illness at the end of life(Keeley 2009). Despite having higher risk factors for delirium, such as cardiovascular disease, sepsis, and respiratory failure, younger African Americans tended to have lower rates of the occurrence of delirium compared with White individuals of similar age in a large case series of ICU patients in the United States(Khan et al. 2016).
Development and Course
The majority of individuals with delirium have a full recovery with or without treatment, especially those who are not elderly(Turkel 2017). Delirium may progress to stupor, coma, seizures, or death, particularly if undetected and the underlying cause(s) remains untreated(Oh et al. 2017; Siddiqi et al. 2016).
There is increasing evidence that delirium may be associated in long-term follow-up with cognitive decline or major NCD in the elderly, particularly in those with preexisting underlying cognitive impairment(Inouye et al. 2016; Salluh et al. 2015). Mortality among hospitalized individuals with delirium is high; as many as 38%–41% of individuals with delirium die within 1 year after diagnosis; the risk of death is particularly great among those with malignancies and other significant underlying medical illness(Salluh et al. 2015; Witlox et al. 2010).
Risk and Prognostic Factors
Delirium may be increased in the context of functional impairment, preexisting cognitive impairment, sensory impairment (e.g., vision/hearing), increasing age, illness severity or comorbidity, infection, depression, history of stroke, and history of alcohol use(Inouye et al. 2014; Lindroth et al. 2018). Both major and mild NCDs can increase the risk for delirium and complicate the course. Falls may be an outcome of delirium but are not found to be a risk factor. In a meta-analysis of studies from 1990 through 2016, anticholinergic use was not a validated predictor of delirium(Lindroth et al. 2018).
Older individuals are especially susceptible to delirium compared with younger adults. Among children, susceptibility to delirium in infancy and through childhood may be associated with significant childhood morbidity and mortality, whereas individuals in early adulthood through mid-adulthood may have less susceptibility to delirium and lower mortality risk(Hatherill and Flisher 2010).
Sex- and Gender-Related Diagnostic Issues
The symptoms associated with delirium may vary in men and women. Men more commonly manifest motor agitation and affective lability, whereas women more commonly manifest hypoactive delirium(Trzepacz et al. 2018). Male sex is a risk factor for delirium(Inouye 2006), and sex- or gender-related factors may interact with other risk factors(Kolanowski et al. 2014).
In addition to laboratory findings characteristic of underlying medical conditions (or intoxication or withdrawal states), there is often generalized irregular theta slowing on electroencephalography, and fast activity is occasionally found (e.g., in some cases of alcohol withdrawal delirium)(Sagi et al. 2016). However, electroencephalography is unable to detect slowing associated with delirium without comparison to premorbid baseline alpha rhythms unless the slowing is in the abnormal theta or delta frequency range(Jacobson and Jerrier 2000).
Functional Consequences of Delirium
Delirium itself is associated with increased functional decline and risk of institutional placement. Hospitalized individuals 65 years or older with delirium are at greater risk for poor outcomes following discharge, including mortality, institutionalization, and dementia(Witlox et al. 2010).
Psychotic disorders and bipolar and depressive disorders with psychotic features
Delirium that is characterized by vivid hallucinations, delusions, language disturbances, and agitation must be distinguished from brief psychotic disorder, schizophrenia, schizophreniform disorder, and other psychotic disorders, as well as from manic or major depressive episodes, with psychotic features.
Acute stress disorder
Delirium associated with fear, anxiety, and dissociative symptoms, such as depersonalization, must be distinguished from acute stress disorder, which is precipitated by exposure to a severely traumatic event.
Malingering and factitious disorder
Delirium can be distinguished from these disorders on the basis of the often atypical symptomatic presentation in malingering and factitious disorder and the absence of another medical condition or substance that is etiologically related to the apparent cognitive disturbance.
Other neurocognitive disorders
The most common differential diagnostic issue when evaluating confusion in older adults is disentangling symptoms of delirium and major NCD. The clinician must determine whether the individual has delirium; a delirium superimposed on a preexisting NCD, such as that due to Alzheimer’s disease; or an NCD without delirium. The traditional distinction between delirium and major NCD according to acuteness of onset and temporal course is particularly difficult in those elderly individuals who had a prior NCD that may not have been recognized, or who developed persistent cognitive impairment following an episode of delirium. When delirium and major NCD are comorbid, the management of the delirium should generally be given priority(Franco et al. 2019; Leonard et al. 2016; Trzepacz et al. 2012)
This chapter begins with a general definition of personality disorder that applies to each of the 10 specific personality disorders. A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the norms and expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.
With any ongoing review process, especially one of this complexity, different viewpoints emerge, and an effort was made to accommodate them. Thus, personality disorders are included in both Sections II and III. The material in Section II represents an update of text associated with the same criteria found in DSM-5 (which were carried over from DSM-IV-TR), whereas Section III includes the proposed model for personality disorder diagnosis and conceptualization developed by the DSM-5 Personality and Personality Disorders Work Group. As this field evolves, it is hoped that both versions will serve clinical practice and research initiatives, respectively.
The following personality disorders are included in this chapter.
Paranoid personality disorder is a pattern of distrust and suspiciousness such that others’ motives are interpreted as malevolent.
Schizoid personality disorder is a pattern of detachment from social relationships and a restricted range of emotional expression.
Schizotypal personality disorder is a pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior.
Antisocial personality disorder is a pattern of disregard for, and violation of, the rights of others, criminality, impulsivity, and a failure to learn from experience.
Borderline personality disorder is a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity.
Histrionic personality disorder is a pattern of excessive emotionality and attention seeking.
Narcissistic personality disorder is a pattern of grandiosity, need for admiration, and lack of empathy.
Avoidant personality disorder is a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.
Dependent personality disorder is a pattern of submissive and clinging behavior related to an excessive need to be taken care of.
Obsessive-compulsive personality disorder is a pattern of preoccupation with orderliness, perfectionism, and control.
Personality change due to another medical condition is a persistent personality disturbance that is judged to be the direct pathophysiological consequence of another medical condition (e.g., frontal lobe lesion).
Other specified personality disorder is a category provided for two situations: 1) the individual’s personality pattern meets the general criteria for a personality disorder, and traits of several different personality disorders are present, but the criteria for any specific personality disorder are not met; or 2) the individual’s personality pattern meets the general criteria for a personality disorder, but the individual is considered to have a personality disorder that is not included in the DSM-5 classification (e.g., passive-aggressive personality disorder). Unspecified personality disorder is for presentations in which symptoms characteristic of a personality disorder are present but there is insufficient information to make a more specific diagnosis.
The personality disorders are grouped into three clusters based on descriptive similarities. Cluster A includes paranoid, schizoid, and schizotypal personality disorders. Individuals with these disorders often appear odd or eccentric. Cluster B includes antisocial, borderline, histrionic, and narcissistic personality disorders. Individuals with these disorders often appear dramatic, emotional, or erratic. Cluster C includes avoidant, dependent, and obsessive-compulsive personality disorders. Individuals with these disorders often appear anxious or fearful. It should be noted that this clustering system, although useful in some research and educational situations, has serious limitations and has not been consistently validated. For instance, two or more disorders from different clusters, or traits from several of them, can often co-occur and vary in intensity and pervasiveness.
A review of epidemiological studies from several countries found a median prevalence of 3.6% for disorders in Cluster A, 4.5% for Cluster B, 2.8% for Cluster C, and 10.5% for any personality disorder(Huang et al. 2009; Morgan and Zimmerman 2018). Prevalence appears to vary across countries and by ethnicity, raising questions about true cross-cultural variation and about the impact of diverse definitions and diagnostic instruments on prevalence assessments(McGilloway et al. 2010; Tyrer et al. 2010).
Dimensional Models for Personality Disorders
The diagnostic approach used in this manual represents the categorical perspective that personality disorders are qualitatively distinct clinical syndromes. An alternative to the categorical approach is the dimensional perspective that personality disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another. See Section III for a full description of a dimensional model for personality disorders. The DSM-5 personality disorder clusters (i.e., odd-eccentric, dramatic-emotional, and anxious-fearful) may also be viewed as dimensions representing spectra of personality dysfunction on a continuum with other mental disorders. The alternative dimensional models have much in common and together appear to cover the important areas of personality dysfunction. Their integration, clinical utility, and relationship with the personality disorder diagnostic categories and various aspects of personality dysfunction continue to be under active investigation. This includes research on whether the dimensional model can clarify the cross-cultural prevalence variations seen with the categorical model(Alarcón et al. 1998; McGilloway et al. 2010; Tyrer et al. 2010).
References: Dimensional Models for Personality Disorders
Alarcón RD, Foulks EF, Vakkur M: Personality Disorders and Culture: Clinical and Conceptual Interactions. New York, Wiley, 1998
Huang Y, Kotov R, de Girolamo G, et al: DSM-IV personality disorders in the WHO World Mental Health Surveys. Br J Psychiatry 195(1):46–53, 2009
McGilloway A, Hall RE, Lee T, Bhui KS: A systematic review of personality disorder, race and ethnicity: prevalence, aetiology and treatment. BMC Psychiatry 10:33, 2010
Morgan TA, Zimmerman M: Epidemiology of personality disorders, in Handbook of Personality Disorders: Theory, Research, and Treatment, 2nd Edition. Edited by Livesley WJ, Larstone R. New York, Guilford, 2018, pp 173–196
Tyrer P, Mulder R, Crawford M, et al: Personality disorder: a new global perspective. World Psychiatry 9(1):56–60, 2010
General Personality Disorder
An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:
Cognition (i.e., ways of perceiving and interpreting self, other people, and events).
Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response).
The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
The enduring pattern is not better explained as a manifestation or consequence of another mental disorder.
The enduring pattern is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., head trauma).
Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts. Only when personality traits are inflexible and maladaptive and cause significant functional impairment or subjective distress do they constitute personality disorders. The essential feature of a personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the norms and expectations of the individual’s culture and is manifested in at least two of the following areas: cognition, affectivity, interpersonal functioning, or impulse control (Criterion A). This enduring pattern is inflexible and pervasive across a broad range of personal and social situations (Criterion B) and leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion C). The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood (Criterion D). The pattern is not better explained as a manifestation or consequence of another mental disorder (Criterion E) and is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, exposure to a toxin) or another medical condition (e.g., head trauma) (Criterion F). Specific diagnostic criteria are also provided for each of the personality disorders included in this chapter.
The diagnosis of personality disorders requires an evaluation of the individual’s long-term patterns of functioning, and the particular personality features must be evident by early adulthood. The personality traits that define these disorders must also be distinguished from characteristics that emerge in response to specific situational stressors or more transient mental states (e.g., bipolar, depressive, or anxiety disorders; substance intoxication). The clinician should assess the stability of personality traits over time and across different situations. Although a single interview with the individual is sometimes sufficient for making the diagnosis, it is often necessary to conduct more than one interview and to space these over time. Assessment can also be complicated by the fact that the characteristics that define a personality disorder may not be considered problematic by the individual (i.e., the traits are often ego-syntonic). To help overcome this difficulty, supplementary information from other informants may be helpful.
Development and Course
The features of a personality disorder usually become recognizable during adolescence or early adult life. By definition, a personality disorder is an enduring pattern of thinking, feeling, and behaving that is relatively stable over time. Some types of personality disorder (notably, antisocial and borderline personality disorders) tend to become less evident or to remit with age, whereas this appears to be less true for some other types (e.g., obsessive-compulsive and schizotypal personality disorders).
Personality disorder categories may be applied with children or adolescents in those relatively unusual instances in which the individual’s particular maladaptive personality traits appear to be pervasive, persistent, and unlikely to be limited to a particular developmental stage or attributable to another mental disorder. It should be recognized that the traits of a personality disorder that appear in childhood will often not persist unchanged into adult life. For a personality disorder to be diagnosed in an individual younger than 18 years, the features must have been present for at least 1 year. The one exception to this is antisocial personality disorder, which cannot be diagnosed in individuals younger than 18 years. Although, by definition, a personality disorder requires an onset no later than early adulthood, individuals may not come to clinical attention until relatively late in life. A personality disorder may be exacerbated following the loss of significant supporting persons (e.g., a spouse) or previously stabilizing social situations (e.g., a job). However, the development of a change in personality in middle adulthood or later life warrants a thorough evaluation to determine the possible presence of a personality change due to another medical condition or an unrecognized substance use disorder.
Culture-Related Diagnostic Issues
Core aspects of personality like emotion regulation and interpersonal functioning are influenced by culture, which also provides means of protection and assimilation and norms for acceptance and denunciation of specific behaviors and personality traits(Ronningstam et al. 2018). Judgments about personality functioning must take into account the individual’s ethnic, cultural, and social background. Personality disorders should not be confused with problems associated with acculturation following migration or with the expression of habits, customs, or religious and political values based on the individual’s cultural background or context. Behavioral patterns that appear to be rigid and dysfunctional aspects of personality disorder may reflect instead adaptive responses to cultural constraints(Balaratnasingam and Janca 2017; Fang et al. 2016; Ronningstam et al. 2018; Ryder et al. 2014). For example, reliance on an abusive relationship in a small community where divorce is proscribed may not reflect pathological dependence; conscientious political protest that puts friends and family members at risk with authorities or in conflict with legal norms does not necessarily reflect pathological callousness(Ryder et al. 2014). There are marked variations in the recognition and diagnosis of personality disorders across cultural, ethnic, and racialized groups(Alarcón et al. 1998; McGilloway et al. 2010; Tyrer et al. 2010). Accuracy of diagnosis can be enhanced by attention to culturally patterned conceptions of self and attachment, assessment biases resulting from clinicians’ own cultural backgrounds or use of diagnostic instruments that are not normed to the population being assessed, and the impact of social determinants such as poverty, acculturative stress, racism, and discrimination on feelings, cognitions, and behaviors(Iacovino et al. 2014; Raza et al. 2014; Ryder et al. 2014). It is useful for the clinician, especially when evaluating someone from a different background, to obtain additional information from informants who are familiar with the person’s cultural background.
Sex- and Gender-Related Diagnostic Issues
Certain personality disorders (e.g., antisocial personality disorder) are diagnosed more frequently in men. Others (e.g., borderline, histrionic, and dependent personality disorders) are diagnosed more frequently in women; however, in the case of borderline personality disorder, this may be due to higher help-seeking among women. Nonetheless, clinicians must be cautious not to overdiagnose or underdiagnose certain personality disorders in women or in men because of social stereotypes about typical gender roles and behaviors. There is currently insufficient evidence on differences between cis- and transgender individuals with respect to the epidemiology or clinical presentations of personality disorders to draw meaningful conclusions.
Other mental disorders and personality traits
Many of the specific criteria for the personality disorders describe features (e.g., suspiciousness, dependency, insensitivity) that are also characteristic of episodes of other mental disorders. A personality disorder should be diagnosed only when the defining characteristics appeared before early adulthood, are typical of the individual’s long-term functioning, and do not occur exclusively during an episode of another mental disorder. It may be particularly difficult (and not particularly useful) to distinguish personality disorders from persistent mental disorders such as persistent depressive disorder that have an early onset and an enduring, relatively stable course. Some personality disorders may have a “spectrum” relationship to other mental disorders (e.g., schizotypal personality disorder with schizophrenia; avoidant personality disorder with social anxiety disorder) based on phenomenological or biological similarities or familial aggregation.
Personality disorders must be distinguished from personality traits that do not reach the threshold for a personality disorder. Personality traits are diagnosed as a personality disorder only when they are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress.