TABLE 3.1.

Comparing Manic and Hypomanic Episodes

Manic episode Hypomanic episode
Duration 1 week or more 4 days or more
Mood Abnormally and persistently high, irritable, or expansive
Activity/energy Persistently increased
Symptoms that are Three or morea of grandiosity, ↓ need for sleep, ↑ talkativeness, flight of ideas or
changes from usual racing thoughts, distractibility (self-report or that of others), agitation or ↑ goal-
behavior directed activity, poor judgment
Severity Results in psychotic features, Clear change from usual functioning and
hospitalization, or impairment of work, Others notice this change and
social, or personal functioning No psychosis, hospitalization, or
impairment
Other Rule out substance/medication-induced symptoms
With mixed features if appropriateb
aFour or more if the only abnormality of mood is irritability.
bBoth manic and hypomanic episodes can have the specifier with mixed features.
 Acute Stress Disorder 225

TABLE 6.1. Comparison of PTSD in Preschool Children, PTSD in Adults, and Acute
Stress Disorder
Child PTSD Adult PTSD Acute Stress Disorder
Trauma
Direct experience Direct experience Direct experience
Witness (not just TV) Witness Witness
Learn of Learn of Learn of
Repeat exposure (not just TV) Repeat exposure (not just TV)

Intrusion symptoms (1/5)a Intrusion symptoms (1/5) All symptoms (9/14)

• Memories • Memories • Memories
• Dreams • Dreams • Dreams
• Dissociative reactions • Dissociative reactions • Dissociative reactions
• Psychological distress • Psychological distress • Psychological distress or
• Physiological reactions • Physiological reactions physiological reactions

Avoid/Neg. emotions (1/6) Avoidance (1/2)

• Avoids memories • Avoids memories • Avoids memories
• Avoids external reminders • Avoids external reminders • Avoids external reminders

Negative emotions (2/7)

• Altered sense of reality of self or
surroundings
• Amnesia • Amnesia
• Negative beliefs
• Distortion → self-blame
• Negative emotional state • Negative emotional state
• Decreased interest • Decreased interest
• Social withdrawal • Detached from others
• Decreased positive emotions • No positive emotions • No positive emotions

Physiological (2/5) Physiological (2/6)

• Irritable, angry • Irritable, angry • Irritable, angry
• Reckless, self-destructive
• Hypervigilance • Hypervigilance • Hypervigilance
• Startle • Startle • Startle
• Poor concentration • Poor concentration • Poor concentration
• Sleep disturbance • Sleep disturbance • Sleep disturbance

Duration
>1 month >1 month 3 days–1 month
aFractions indicate the number of symptoms required of the number possible in the following list.
 CHAPTER 17

Personality Disorders

Quick Guide to the Personality Disorders

DSM-5 retains the 10 speci c personality disorders (PDs) that were listed in DSM-IV. Of these,
perhaps 6 have been studied reasonably well and have a lot of support in the research com-
munity. The rest (paranoid, schizoid, histrionic, and dependent PDs), while perhaps less well
founded in science, retain their positions in the diagnostic rmament because of their prac-
tical use and, frankly, tradition.
Speaking of tradition, ever since DSM-III in 1980 the personality disorders have been
divided into three groups, called clusters. Heavily criticized for a lack of scienti c validity,
the clusters are perhaps most useful as a device to help us call to mind the full slate of PDs.

Cluster A Personality Disorders

People with Cluster A PDs can be described as withdrawn, cold, suspicious, or irrational.
(Here and throughout the Quick Guide, as usual, the page number following each item indi-
cates where a more detailed discussion begins.)

Paranoid. These people are suspicious and quick to take offense. They often have few con -
dants and may read hidden meaning into innocent remarks (p. 533).

Schizoid. These patients care little for social relationships, have a restricted emotional range,
and seem indifferent to criticism or praise. Tending to be solitary, they avoid close (including
sexual) relationships (p. 535).

Schizotypal. Interpersonal relationships are so dif cult for these people that they appear
peculiar or strange to others. They lack close friends and are uncomfortable in social situa-
tions. They may show suspiciousness, unusual perceptions or thinking, eccentric speech, and
inappropriate affect (p. 538).

528
 Quick Guide to the Personality Disorders 529

Cluster B Personality Disorders

Those with Cluster B PDs tend to be rather theatrical, emotional, and attention-seeking;
their moods are labile and often shallow. They often have intense interpersonal con icts.

Antisocial. The irresponsible, often criminal behavior of these people begins in childhood
or early adolescence with truancy, running away, cruelty, ghting, destructiveness, lying,
and theft. In addition to criminal behavior, as adults they may default on debts or otherwise
behave irresponsibly; act recklessly or impulsively; and show no remorse for their behavior
(p. 541).

Borderline. These impulsive people engage in behavior harmful to themselves (sexual

adventures, unwise spending, excessive use of substances or food). Affectively unstable,
they often show intense, inappropriate anger. They feel empty or bored, and they frantically
try to avoid abandonment. They are uncertain about who they are, and they lack the ability
to maintain stable interpersonal relationships (p. 545).

Histrionic. Overly emotional, vague, and desperate for attention, these people need con-
stant reassurance about their attractiveness. They may be self- centered and sexually seduc-
tive (p. 548).

Narcissistic. These people are self-important and often preoccupied with envy, fantasies of
success, or ruminations about the uniqueness of their own problems. Their sense of entitle-
ment and lack of compassion may cause them to take advantage of others. They vigorously
reject criticism and need constant attention and admiration (p. 550).

Cluster C Personality Disorders

Someone with a Cluster C PD will tend to be anxious and tense, often overcontrolled.

Avoidant. These timid people are so easily wounded by criticism that they hesitate to become
involved with others. They may fear the embarrassment of showing emotion or of saying
things that seem foolish. They may have no close friends, and they exaggerate the risks of
undertaking pursuits outside their usual routines (p. 553).

Dependent. These people so much need the approval of others that they have trouble mak-
ing independent decisions or starting projects; they may even agree with others whom they
know to be wrong. They fear abandonment, feel helpless when they are alone, and are
miserable when relationships end. They are easily hurt by criticism and will even volunteer
for unpleasant tasks to gain the favor of others (p. 556).

Obsessive– Compulsive. Perfectionism and rigidity characterize these people. They are often
workaholics, and they tend to be indecisive, excessively scrupulous, and preoccupied with
detail They insist that others do things their way. They have trouble expressing affection,
 Introduction 531

As currently defined in DSM-5, all PDs have in common the following character-
istics.

Essential Features of a General Personality Disorder

There is a lasting pattern of behavior and internal experience (thoughts, feelings,
sensations) that is clearly different from the patient’s culture. This pattern includes
problems with affect (type, intensity, lability, appropriateness); cognition (how the
patient sees and interprets self and the environment); control of impulses; and inter-
personal relationships. This pattern is xed and applies broadly across the patient’s
social and personal life.

The Fine Print

The D’s: • Duration (lifelong, with roots in adolescence or childhood) • Diffuse con-
texts • Distress and disability (work/educational, social, and personal) • Differential
diagnosis (substance use, physical illness, other mental disorders, other PDs, person-
ality change due to another medical condition)

The information PDs convey gives the clinician a better understanding of the
behavior of patients; it can also augment our understanding of the management of many
patients.
As you read these descriptions and the accompanying vignettes, keep in mind the
twin hallmarks of the PDs: early onset (usually by late teens) and pervasive nature, such
that a disorder’s features affect multiple aspects of work, personal, and social life.

Diagnosing Personality Disorders

The diagnosis of PDs presents a variety of problems. On the one hand, they are often
overlooked; on the other, however, they are sometimes overdiagnosed (borderline PD
is, in my opinion, a notorious example). One (antisocial PD) carries a terrible prognosis;
most, if not all, are hard to treat. Their relatively weak validity suggests that no PD
should be the sole diagnosis when another mental disorder can explain the signs and
symptoms that make up the clinical picture. For all of these reasons, it is a good idea to
have in mind an outline for making the diagnosis of a PD.

1. Verify the duration of the symptoms. Make sure that your patient’s symptoms
have been present at least since early adulthood (before age 15 for antisocial
PD). Interviewing informants (family, friends, coworkers) will probably give
you the most valid material.
2. Verify that the symptoms affect several areas of the patient’s life. Specifically,
532 PERSONALITY DISORDERS

are work (or school), home life, personal life, and social life affected? This step
can present real problems, in that patients themselves often don’t see their
behavior as causing problems. (“It’s the world that’s out of step.”)
3. Check that the patient fully qualifies for the particular diagnosis in question.
This means checking all the characteristics and consulting all 10 sets of diag-
nostic criteria. Sometimes you have to make a judgment call. Try to be as objec-
tive as possible. As with other mental disorders, with enough motivation you
can usually force a patient into a variety of diagnoses.
4. If the patient is under age 18, make sure that the symptoms have been present
for at least the past 12 months. (And be really, really sure that they aren’t due
instead to some other mental or physical disorder.) I personally prefer not mak-
ing such a diagnosis at such a tender age.
5. Rule out other mental pathology that may be more acute and have greater
potential for doing harm. The flip side is that other mental disorders are also
often more responsive to treatment than are PDs.
6. This is also a good time to review the generic features for any other require-
ments you may have missed. Note that each patient must have two or more
types of lasting problems with behavior, thoughts, or emotions from a list of
four: cognitive, affective, interpersonal, and impulsive. (This helps ensure that
the patient’s problems truly do affect more than one life area.)
7. Search for other PDs. Evaluate the entire history to learn whether any addi-
tional PD is present. Many patients appear to have more than one PD; in such
cases, diagnose them all. Perhaps more often, you will find too few symptoms
to make any diagnosis. Then you can add to your summary note something to
the effect: schizoid and paranoid personality traits.
8. Record all personality and nonpersonality mental diagnoses. Some examples of
how this is done are shown in the vignettes that follow.

Although you can learn the rudiments of each PD from the material I present here,
it is important to note that these abbreviated descriptions only begin to tap their rich
psychopathology. If you want to make a study of these disorders, I strongly recommend
that you consult standard texts.

Cluster A Personality Disorders

The PDs included in Cluster A share behaviors generally described as withdrawn, cold,
suspicious, or irrational.
 Quick Guide to the Mood Disorders 111

SPECIFIERS DESCRIBING CURRENT OR MOST RECENT EPISODE

These descriptors help characterize the most recent major depressive episode; all but the
rst two can also apply to a manic episode. (Note that the speci ers for severity and remis-
sion are described on p. 158.)

With atypical features. These depressed patients eat a lot and gain weight, sleep excessively,
and have a feeling of being sluggish or paralyzed. They are often excessively sensitive to
rejection (p. 160).

With melancholic features. This term applies to major depressive episodes characterized by
some of the “classic” symptoms of severe depression. These patients awaken early, feeling
worse than they do later in the day. They lose appetite and weight, feel guilty, are either
slowed down or agitated, and do not feel better when something happens that they would
normally like (p. 161).

With anxious distress. A patient has symptoms of anxiety, tension, restlessness, worry, or
fear that accompanies a mood episode (p. 159).

With catatonic features. There are features of either motor hyperactivity or inactivity. Cata-
tonic features can apply to major depressive episodes and to manic episodes (p. 100).

With mixed features. Manic, hypomanic, and major depressive episodes may have mixtures
of manic and depressive symptoms (p. 161).

With peripartum onset. A manic, hypomanic, or major depressive episode (or a brief psy-
chotic disorder) can occur in a woman during pregnancy or within a month of having a baby
(p. 163).

With psychotic features. Manic and major depressive episodes can be accompanied by delu-
sions, which can be mood- congruent or -incongruent (p. 164).

SPECIFIERS DESCRIBING COURSE OF RECURRING EPISODES

These speci ers describe the overall course of a mood disorder, not just the form of an indi-
vidual episode.

With rapid cycling. Within 1 year, the patient has had at least four episodes (in any combina-
tion) ful lling criteria for major depressive, manic, or hypomanic episodes (p. 165).

With seasonal pattern. These patients regularly become ill at a certain time of the year, such
as fall or winter (p. 165).