Functional Neurological Symptom Disorder Diagnostic Criteria
A. One or more symptoms of altered voluntary motor or sensory function.
B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.
C. The symptom or deficit is not better explained by another medical or mental disorder.
D. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.FNSD Specifiers
With weakness or paralysis
With abnormal movement (e.g., tremor, dystonia, myoclonus, gait disorder)
With swallowing symptoms
With speech symptom (e.g., dysphonia, slurred speech)
With attacks or seizures
With anesthesia or sensory loss
With special sensory symptom (e.g., visual, olfactory, or hearing disturbance)
With mixed symptomsAssociated Features
In functional neurological symptom disorder (conversion disorder), there may be one or more neurological symptoms of various types. Motor symptoms include weakness or paralysis; abnormal movements, such as tremor, jerks, or dystonic movements; and gait abnormalities. Sensory symptoms include altered, reduced, or absent skin sensation, vision, or hearing. Episodes of apparent unresponsiveness with or without limb movements may resemble epileptic seizures, syncope, or coma (also called dissociative, psychogenic, or nonepileptic seizures or attacks). Other symptoms include reduced or absent speech volume (dysphonia/aphonia); altered speech articulation, prosody, or fluency; a sensation of a lump in the throat (globus); and diplopia. This disorder has been called “conversion disorder” in prior editions of DSM as well as in much of the psychiatric research literature. The term “conversion” originated in psychoanalytic theory, which proposes that unconscious psychic conflict is “converted” into physical symptoms.

Functional neurological symptom disorder is often associated with dissociative symptoms, such as depersonalization, derealization, and dissociative amnesia, particularly at symptom onset or during attacks. The phenomenon of la belle indifférence (i.e., lack of concern about the nature or implications of the symptom) has been associated with functional neurological symptom disorder, but it is not specific and should not be used to make the diagnosis. Similarly, the concept of secondary gain (i.e., when individuals derive external benefits such as money or release from responsibilities) is also not specific to functional neurological symptom disorder.Comorbid Disorders
Anxiety disorders, especially panic disorder, and depressive disorders commonly co-occur with functional neurological symptom disorder. Somatic symptom disorder may co-occur as well. Personality disorders are more common in individuals with functional neurological symptom disorder than in the general population. Neurological or other medical conditions commonly coexist with functional neurological symptom disorder as well.←

Factitious Disorder Imposed on Self Diagnostic Criteria
A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.
B. The individual presents himself or herself to others as ill, impaired, or injured.
C. The deceptive behavior is evident even in the absence of obvious external rewards.
D. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.Factitious Disorder Imposed on Another Diagnostic Criteria
A. Falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with identified deception.
B. The individual presents another individual (victim) to others as ill, impaired, or injured.
C. The deceptive behavior is evident even in the absence of obvious external rewards.
D. The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.Associated Features
The essential feature of factitious disorder is the falsification of medical or psychological signs and symptoms in the individual or others that are associated with the identified deception. The diagnosis requires demonstrating that the individual is taking surreptitious actions to misrepresent, simulate, or cause signs or symptoms of illness or injury even in the absence of obvious external rewards. The diagnosis of factitious disorder emphasizes the objective identification of falsification of signs and symptoms of illness and not the individual motivations of the falsifier.

Methods of illness falsification can include exaggeration, fabrication, simulation, and induction. While a pre-existing medical condition may be present, the deceptive behavior or induction of injury associated with deception causes others to view such individuals as more ill or impaired, and this can lead to excessive clinical intervention. Individuals with factitious disorder might, for example, report feelings of depression and suicidal thoughts or behavior following the death of a spouse despite the death not being true or the individual’s not having a spouse; deceptively report episodes of neurological symptoms; manipulate a laboratory test to falsely indicate an abnormality; falsify medical records to indicate an illness; ingest a substance to induce an abnormal laboratory result or illness; or physically injure themselves or induce illness in themselves or another. Although individuals with factitious disorder most often present to health care professionals for treatment of their factitious symptoms, some individuals with factitious disorder choose to mislead community members in person or online about illness or injury without necessarily engaging health care professionals.Differential Diagnoses
Malingering: Malingering is differentiated from factitious disorder by the intentional reporting of
symptoms for personal gain (e.g., money, time off work). In contrast, the diagnosis of factitious disorder requires that the illness falsification is not fully accounted for by external rewards. Factitious disorder and malingering are not mutually exclusive, however. The motives in any single case might be multiple and shifting depending on the circumstances and reactions of others.←

Pica Diagnostic Criteria
A. Persistent eating of nonnutritive, nonfood substances over a period of at least 1 month.
B. The eating of nonnutritive, nonfood substances is inappropriate to the developmental level of the individual.
C. The eating behavior is not part of a culturally supported or socially normative practice.
D. If the eating behavior occurs in the context of another mental disorder (e.g., intellectual developmental disorder [intellectual disability], autism spectrum disorder, schizophrenia) or medical condition, it is sufficiently severe to warrant additional clinical attention.Differential Diagnoses
Eating of nonnutritive, nonfood substances may occur during the course of other mental disorders (e.g., autism spectrum disorder, schizophrenia) and in Kleine-Levin syndrome. In any
such instance, an additional diagnosis of pica should be given only if the eating behavior is
sufficiently persistent and severe to warrant additional clinical attention.

Anorexia Nervosa: Pica can usually be distinguished from the other feeding and eating disorders by the consumption of nonnutritive, nonfood substances. It is important to note, however, that some presentations of anorexia nervosa include ingestion of nonnutritive, nonfood substances, such as paper tissues, as a means of attempting to control appetite. In such cases, when the eating of nonnutritive, nonfood substances is primarily used as a means of weight control, anorexia nervosa should be the primary diagnosis.Comorbid Disorders
Disorders most commonly comorbid with pica are autism spectrum disorder and intellectual developmental disorder (intellectual disability) and, to a lesser degree, schizophrenia and obsessive-compulsive disorder. Pica can be associated with trichotillomania (hair-pulling disorder) and excoriation (skin-picking) disorder. In comorbid presentations, the hair or skin is typically ingested. Pica can also be associated with avoidant/restrictive food intake disorder, particularly in individuals with a strong sensory component to their presentation. When an individual is known to have pica, assessment should include consideration of the possibility of gastrointestinal complications, poisoning, infection, and nutritional deficiency.←

The diagnostic criteria for rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, and binge-eating disorder result in a classification scheme that is mutually exclusive, so that during a single episode, only one of these diagnoses can be assigned. The rationale for this approach is that, despite a number of common psychological and behavioral features, the disorders differ substantially in clinical course, outcome, and treatment needs. A diagnosis of pica, however, may be assigned in the presence of any other feeding and eating disorder.:::::::Avoidant/Restrictive Food Intake Disorder Diagnostic Criteria
A. An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) associated with one (or more) of the following:
::::::::::::::1. Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
::::::::::::::2. Significant nutritional deficiency.
::::::::::::::3. Dependence on enteral feeding or oral nutritional supplements.
::::::::::::::4. Marked interference with psychosocial functioning.
B. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.
C. The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced.
D. The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.:::::::Associated Features
In some individuals, food avoidance or restriction is based on the sensory characteristics of qualities of food, such as extreme sensitivity to appearance, color, smell, texture, temperature, or taste. Such behavior has been described as “restrictive eating,” “selective eating,” “choosy eating,” “perseverant eating,” “chronic food refusal,” and “food neophobia” and may manifest as refusal to eat particular brands of foods or to tolerate the smell of food being eaten by others. Individuals with heightened sensory sensitivities associated with autism may show similar behaviors.

In other individuals, food avoidance or restriction represents a conditioned negative response associated with food intake following, or in anticipation of, an aversive experience, such as choking; a traumatic procedure, usually involving the gastrointestinal tract; or repeated vomiting. In yet other individuals, food avoidance or restriction manifests as a lack of interest in eating or food.

Restriction of energy intake relative to requirements leading to significantly low body weight is a core feature of anorexia nervosa. However, individuals with anorexia nervosa also display a fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, as well as specific disturbances in relation to perception and experience of their own body weight and shape. These features are not present in avoidant/restrictive food intake disorder, and the two disorders should not be diagnosed concurrently.:::::::Differential Diagnoses
Autism Spectrum Disorder: Individuals with autism spectrum disorder often present with rigid eating behaviors and heightened sensory sensitivities. However, these features do not always result in the level of impairment that would be required for a diagnosis of avoidant/restrictive food intake disorder. Avoidant/restrictive food intake disorder should be diagnosed concurrently only if all criteria are met for both disorders and when the eating disturbance requires specific treatment.

Anxiety Disorders: Specific phobia, other type, includes as an example “situations that may lead to choking or vomiting” and can represent the primary trigger for the fear, anxiety, or avoidance required for diagnosis. Distinguishing specific phobia from avoidant/restrictive food intake disorder can be difficult when a fear of choking or vomiting has resulted in food avoidance. Although avoidance or restriction of food intake secondary to a pronounced fear of choking or vomiting can be conceptualized as specific phobia, in situations when the eating problem becomes the primary focus of clinical attention, avoidant/restrictive food intake disorder becomes the appropriate diagnosis. In social anxiety disorder, the individual may present with a fear of being observed by others while eating, which can also occur in avoidant/restrictive food intake disorder.

Anorexia Nervosa: Restriction of energy intake relative to requirements leading to significantly low body weight is a core feature of anorexia nervosa. However, individuals with anorexia nervosa also display a fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, as well as specific disturbances in relation to perception and experience of their own body weight and shape. These features are not present in avoidant/restrictive food intake disorder, and the two disorders should not be diagnosed concurrently. Differential diagnosis between avoidant/restrictive food intake disorder and anorexia nervosa may be difficult, especially in late childhood and early adolescence, because these disorders may share a number of common symptoms (e.g., food avoidance, low weight). Differential diagnosis is also potentially difficult in individuals with anorexia nervosa who deny any fear of fatness but nonetheless engage in persistent behaviors that prevent weight gain and who do not recognize the medical seriousness of their low weight—a presentation sometimes termed “non–fat phobic anorexia nervosa.” Full consideration of symptoms, course, and family history is advised, and diagnosis may be best made in the context of a clinical relationship over time. In some individuals, avoidant/restrictive food intake disorder might precede the onset of anorexia nervosa.:::::::Comorbid Disorders
The most commonly observed disorders comorbid with avoidant/restrictive food intake disorder are anxiety disorders, obsessive-compulsive disorder, and neurodevelopmental disorders (specifically autism spectrum disorder, attention-deficit/hyperactivity disorder, and intellectual developmental
disorder [intellectual disability]).←

The diagnostic criteria for rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, and binge-eating disorder result in a classification scheme that is mutually exclusive, so that during a single episode, only one of these diagnoses can be assigned. The rationale for this approach is that, despite a number of common psychological and behavioral features, the disorders differ substantially in clinical course, outcome, and treatment needs. A diagnosis of pica, however, may be assigned in the presence of any other feeding and eating disorder.:::::::Anorexia Nervosa Diagnostic Criteria
A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.
B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.
C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.Specifiers
Restricting type: During the last 3 months, the individual has not engaged in recurrent episodes of binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise.
Binge-eating/purging type: During the last 3 months, the individual has engaged in recurrent episodes of binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).:::::::Associated Features
Obsessive-compulsive features, both related and unrelated to food, are often prominent. Most individuals with anorexia nervosa are preoccupied with thoughts of food. Some collect recipes or hoard food. Observations of behaviors associated with other forms of starvation suggest that obsessions and compulsions related to food may be exacerbated by undernutrition. When individuals with anorexia nervosa exhibit obsessions and compulsions that are not related to food, body shape, or weight, an additional diagnosis of obsessive-compulsive disorder (OCD) may be warranted.

Other features sometimes associated with anorexia nervosa include concerns about eating in public, feelings of ineffectiveness, a strong desire to control one’s environment, inflexible thinking, limited social spontaneity, and overly restrained emotional expression.Many individuals have a period of changed eating behavior prior to full criteria for the disorder being met. Some individuals with anorexia nervosa recover fully after a single episode, with some exhibiting a fluctuating pattern of weight gain followed by relapse, and others experiencing a chronic course over many years.:::::::Differential Diagnoses
Bulimia Nervosa: Individuals with bulimia nervosa exhibit recurrent episodes of binge eating,
engage in purging behavior to avoid weight gain, and are overly concerned with body shape and weight. However, unlike individuals with anorexia nervosa, binge-eating/purging type, individuals with bulimia nervosa maintain body weight at or above a minimally normal level.

Avoidant/Restrictive Food Intake Disorder: Individuals with this disorder may exhibit significant weight loss or significant nutritional deficiency, but they do not have a fear of gaining weight or of becoming fat, nor do they have a disturbance in the way they experience their body shape and weight.

Social Anxiety Disorder, OCD, and Body Dysmorphic Disorder: Some of the features of anorexia nervosa overlap with the criteria for social anxiety disorder, OCD, and body dysmorphic disorder. Specifically, individuals may feel humiliated or embarrassed to be seen eating in public, as in social anxiety disorder; may exhibit obsessions and compulsions related to food, as in OCD; or may be preoccupied with an imagined defect in bodily appearance, as in body dysmorphic disorder. If the individual with anorexia nervosa has social fears that are limited to eating behavior alone, the diagnosis of social anxiety disorder should not be made, but social fears unrelated to eating behavior (e.g., excessive fear of speaking in public) may warrant an additional diagnosis of social anxiety disorder. Similarly, an additional diagnosis of OCD should be considered only if the individual exhibits obsessions and compulsions unrelated to food (e.g., an excessive fear of contamination), and an additional diagnosis of body dysmorphic disorder should be considered only if the distortion is unrelated to body shape and size.:::::::Comorbid Disorders
Bipolar, depressive, and anxiety disorders commonly co-occur with anorexia nervosa. Many individuals with anorexia nervosa report the presence of either an anxiety disorder or symptoms of anxiety prior to onset of their eating disorder. OCD is described in some individuals with anorexia nervosa, especially those with the restricting type. Alcohol use disorder and other substance use disorders may also be comorbid with anorexia nervosa, especially among those with the binge-eating/purging type.←

The diagnostic criteria for rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, and binge-eating disorder result in a classification scheme that is mutually exclusive, so that during a single episode, only one of these diagnoses can be assigned. The rationale for this approach is that, despite a number of common psychological and behavioral features, the disorders differ substantially in clinical course, outcome, and treatment needs. A diagnosis of pica, however, may be assigned in the presence of any other feeding and eating disorder.:::::::Bulimia Nervosa Diagnostic Criteria
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
::::::::::::::1. Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.
::::::::::::::2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.
D. Self-evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of anorexia nervosa.:::::::Associated Features
Individuals with bulimia nervosa are typically ashamed of their eating problems and attempt to conceal their symptoms. Binge eating usually occurs in secrecy or as inconspicuously as possible. The binge eating often continues until the individual is uncomfortably, or even painfully, full. The most common antecedent of binge eating is negative affect. Other triggers include interpersonal stressors; dietary restraint; negative feelings related to body weight, body shape, and food; and boredom. Binge eating may minimize or mitigate factors that precipitated the episode in the short-term, but negative self-evaluation and dysphoria often are the delayed consequences.:::::::Differential Diagnoses
Anorexia Nervosa, binge-eating/purging type: Individuals whose binge-eating behavior occurs only during episodes of anorexia nervosa are given the diagnosis anorexia nervosa, binge-eating/purging type, and should not be given the additional diagnosis of bulimia nervosa. For individuals with an initial diagnosis of anorexia nervosa who binge and purge but whose presentation no longer meets the full criteria for anorexia nervosa, binge-eating/purging type (e.g., when weight is normal), a diagnosis of bulimia nervosa should be given only when all criteria for bulimia nervosa have been met for at least 3 months.

Binge-Eating Disorder: Some individuals binge eat but do not engage in regular inappropriate compensatory behaviors. In these cases, the diagnosis of binge-eating disorder should be considered.

Major Depressive Disorder, with atypical features: Overeating is common in major depressive disorder, with atypical features, but individuals with this disorder do not engage in inappropriate compensatory behaviors and do not exhibit the excessive concern with body shape and weight characteristic of bulimia nervosa. If criteria for both disorders are met, both diagnoses should be given.

Borderline Personality Disorder: Binge-eating behavior is included in the impulsive behavior criterion that is part of the definition of borderline personality disorder. If the criteria for both borderline personality disorder and bulimia nervosa are met, both diagnoses should be given.:::::::Comorbid Disorders
Comorbidity with mental disorders is common in individuals with bulimia nervosa, with most experiencing at least one other mental disorder and many experiencing multiple comorbidities. Comorbidity is not limited to any particular subset but rather occurs across a wide range of mental disorders. There is an increased frequency of depressive symptoms (e.g., low self-esteem) and bipolar and depressive disorders (particularly depressive disorders) in individuals with bulimia nervosa. In many individuals, the mood disturbance begins at the same time as or following the development of bulimia nervosa, and individuals often ascribe their mood disturbances to the bulimia nervosa. However, in some individuals, the mood disturbance clearly precedes the development of bulimia nervosa. There may also be an increased frequency of anxiety symptoms (e.g., fear of social situations) or anxiety disorders. These mood and anxiety disturbances frequently remit following effective treatment of the bulimia nervosa.←

The diagnostic criteria for rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, and binge-eating disorder result in a classification scheme that is mutually exclusive, so that during a single episode, only one of these diagnoses can be assigned. The rationale for this approach is that, despite a number of common psychological and behavioral features, the disorders differ substantially in clinical course, outcome, and treatment needs. A diagnosis of pica, however, may be assigned in the presence of any other feeding and eating disorder.:::::::Binge-Eating Disorder Diagnostic Criteria
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
::::::::::::::1. Eating, in a discrete period of time, an amount of food that is definitely larger than
what most people would eat in a similar period of time under similar circumstances.
::::::::::::::2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
B. The binge-eating episodes are associated with three (or more) of the following:
::::::::::::::1. Eating much more rapidly than normal.
::::::::::::::2. Eating until feeling uncomfortably full.
::::::::::::::3. Eating large amounts of food when not feeling physically hungry.
::::::::::::::4. Eating alone because of feeling embarrassed by how much one is eating.
::::::::::::::5. Feeling disgusted with oneself, depressed, or very guilty afterward.
C. Marked distress regarding binge eating is present.
D. The binge eating occurs, on average, at least once a week for 3 months.
E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia
nervosa or anorexia nervosa.:::::::Associated Features
The context in which the eating occurs may affect the estimation of whether the intake is excessive. For example, a quantity of food that might be regarded as excessive for a typical meal might be considered normal during a celebration or holiday meal. A “discrete period of time” refers to a limited period, usually less than 2 hours. A single episode of binge eating need not be restricted to one setting. For example, an individual may begin a binge in a restaurant and then continue to eat on returning home. Continual snacking on small amounts of food throughout the day would not be considered an eating binge.
:
Some individuals describe a dissociative quality during, or following, the binge-eating episodes. The impairment in control associated with binge eating may not be absolute; for example, an individual may continue binge eating while the telephone is ringing but will cease if a roommate or spouse unexpectedly enters the room. Some individuals report that their binge-eating episodes are no longer characterized by an acute feeling of loss of control but rather by a more generalized pattern of uncontrolled eating. If individuals report that they have abandoned efforts to control their eating, loss of control may still be considered as present. Binge eating can also be planned in some instances.:::::::Differential Diagnoses
Bulimia Nervosa: Binge-eating disorder has recurrent binge eating in common with bulimia
nervosa but differs from the latter disorder in some fundamental respects. In terms of clinical
presentation, the recurrent inappropriate compensatory behavior (e.g., purging, driven exercise) seen in bulimia nervosa is absent in binge-eating disorder. Unlike individuals with bulimia nervosa, individuals with binge-eating disorder typically do not show marked or sustained dietary restriction designed to influence body weight and shape between binge-eating episodes. They may, however, report frequent attempts at dieting.

Bipolar and Depressive Disorders: Increases in appetite and weight gain are included in the criteria for major depressive episode and in the atypical features specifiers for depressive and bipolar disorders. Increased eating in the context of a major depressive episode may or may not be associated with loss of control. If the full criteria for both disorders are met, both diagnoses can be given. Binge eating and other symptoms of disordered eating are seen in association with bipolar disorder. If the full criteria for both disorders are met, both diagnoses should be given.

Borderline Personality Disorder: Binge eating is included in the impulsive behavior criterion that is part of the definition of borderline personality disorder. If the full criteria for both disorders are met, both diagnoses should be given.:::::::Comorbid Disorders
Binge-eating disorder is associated with significant psychiatric comorbidity that is comparable to that of bulimia nervosa and anorexia nervosa. The most common comorbid disorders are major depressive disorder and alcohol use disorder.←

Other Specified Feeding or Eating Disorder
This category applies to presentations in which symptoms characteristic of a feeding and eating disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the feeding and eating disorders diagnostic class. The other specified feeding or eating disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific feeding and eating disorder.

Examples of presentations that can be specified using the “other specified” designation include:

1. Atypical anorexia nervosa: All of the criteria for anorexia nervosa are met, except that despite significant weight loss, the individual’s weight is within or above the normal range. Individuals with atypical anorexia nervosa may experience many of the physiological complications associated with
anorexia nervosa.
2. Bulimia nervosa (of low frequency and/or limited duration): All of the criteria for bulimia nervosa are met, except that the binge eating and inappropriate compensatory behaviors occur, on average, less than once a week and/or for less than 3 months.
3. Binge-eating disorder (of low frequency and/or limited duration): All of the criteria for binge-eating disorder are met, except that the binge eating occurs, on average, less than once a week and/or for less than 3 months.
4. Purging disorder: Recurrent purging behavior to influence weight or shape (e.g., self-induced vomiting; misuse of laxatives, diuretics, or other medications) in the absence of binge eating.
5. Night eating syndrome: Recurrent episodes of night eating, as manifested by eating after awakening from sleep or by excessive food consumption after the evening meal. There is awareness and recall of the eating. The night eating is not better explained by external influences such as changes in the individual’s sleep-wake cycle or by local social norms. The night eating causes significant distress and/or impairment in functioning. The disordered pattern of eating is not better explained by binge-eating disorder or another mental disorder, including substance use, and is not attributable to another medical condition or to an effect of medication.←

Insomnia Disorder Diagnostic Criteria
A. A predominant complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms:
::::::::::::::1. Difficulty initiating sleep.
::::::::::::::2. Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings.
::::::::::::::3. Early-morning awakening with inability to return to sleep.
B. The sleep disturbance causes clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning.
C. The sleep difficulty occurs at least 3 nights per week.
D. The sleep difficulty is present for at least 3 months.
E. The sleep difficulty occurs despite adequate opportunity for sleep.
F. The insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder.
G. The insomnia is not attributable to the physiological effects of a substance.
H. Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia.Associated Features
Insomnia disorder involves daytime impairments as well as nighttime sleep difficulties. These include fatigue or, less commonly, daytime sleepiness; the latter is more common among older individuals and when insomnia is comorbid with another medical condition (e.g., chronic pain) or sleep disorder (e.g., sleep apnea). Impairment in cognitive performance may include difficulties with attention, concentration and memory, and performing complex manual skills. Associated mood disturbances are typically described as irritability or mood lability and less commonly as depressive or anxiety symptoms.Differential Diagnoses
Normal sleep variations: Normal sleep duration varies considerably across persons. Some
individuals who require little sleep (“short sleepers”) may be concerned about their sleep duration. Short sleepers differ from individuals with insomnia disorder by the lack of difficulty falling or staying asleep and by the absence of characteristic daytime symptoms (e.g., fatigue, concentration problems, irritability). However, some short sleepers may desire or attempt to sleep for a longer period of time and, by prolonging time in bed, may create an insomnia-like sleep pattern. Clinical insomnia also should be distinguished from normal, age-related sleep changes. Insomnia must also be distinguished from sleep deprivation attributable to inadequate opportunity or circumstance for sleep resulting, for example, from an emergency or from professional or family obligations forcing the individual to stay awake.

Situational/Acute Insomnia: Situational/acute insomnia is a condition lasting a few days to several weeks, often associated with acute stress due to life events or with changes in sleep schedules. These acute or short-term insomnia symptoms may also produce significant distress and interfere with social, personal, and occupational functioning. When such symptoms
are frequent enough and meet all other criteria except for the 3-month duration, a diagnosis of other specified insomnia disorder or unspecified insomnia disorder is made. While the disorder often remits with subsidence of the stress or adjustment to the change in sleep schedule, some individuals will develop maladaptive patterns of thought and behavior that result in the development of a chronic insomnia disorder.Comorbid Disorders
Individuals with insomnia disorder frequently have a comorbid mental disorder, particularly bipolar, depressive, and anxiety disorders. Persistent insomnia represents a risk factor or an early symptom of subsequent bipolar, depressive, anxiety, and substance use disorders. Individuals with insomnia may misuse medications or alcohol to help with nighttime sleep, anxiolytics to combat tension or anxiety, and caffeine or other stimulants to combat excessive daytime fatigue. In addition to worsening the insomnia, this type of substance use may in some cases progress to a substance use disorder.←

Hypersomnolence Disorder Diagnostic Criteria
A. Self-reported excessive sleepiness (hypersomnolence) despite a main sleep period lasting at least 7 hours, with at least one of the following symptoms:
::::::::::::::1. Recurrent periods of sleep or lapses into sleep within the same day.
::::::::::::::2. A prolonged main sleep episode of more than 9 hours per day that is nonrestorative (i.e., unrefreshing).
::::::::::::::3. Difficulty being fully awake after abrupt awakening.
B. The hypersomnolence occurs at least three times per week, for at least 3 months.
C. The hypersomnolence is accompanied by significant distress or impairment in cognitive, social, occupational, or other important areas of functioning.
D. The hypersomnolence is not better explained by and does not occur exclusively during the course of another sleep disorder (e.g., narcolepsy, breathing-related sleep disorder, circadian rhythm sleep-wake disorder, or a parasomnia).
E. The hypersomnolence is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).
F. Coexisting mental and medical disorders do not adequately explain the predominant complaint of hypersomnolence.Associated Features
About 40% of individuals with hypersomnolence disorder may have sleep inertia, and this symptom may help differentiate hypersomnolence disorder from other causes of sleepiness. They may have difficulty waking up in the morning, sometimes appearing confused, combative, or ataxic. Individuals may set multiple alarm clocks or rely on others to help get them out of bed. Sleep inertia can also occur upon awakening from a daytime nap. During that period, the individual appears awake, but motor coordination is impaired, behavior may be inappropriate, and memory deficits, disorientation in time and space, and feelings of grogginess may occur. This period may last some minutes to hours.Differential Diagnoses
Normative variations in sleep: “Normal” sleep duration varies considerably in the general
population. “Long sleepers” (i.e., persons who require a greater than average amount of sleep) do
not have excessive sleepiness, sleep inertia, or automatic behavior when they obtain their required amount of nocturnal sleep. Sleep is reported to be refreshing. If social or occupational demands lead to shorter nocturnal sleep, daytime symptoms may appear. In hypersomnolence disorder, by contrast, symptoms of excessive sleepiness occur regardless of nocturnal sleep duration. An inadequate amount of nocturnal sleep, or behaviorally induced insufficient sleep syndrome, can produce symptoms of daytime sleepiness very similar to those of hypersomnolence disorder. An average sleep duration of fewer than 7 hours per night strongly suggests inadequate nocturnal sleep, yet in the United States, the average adult obtains only 6.75 hours of sleep on typical weeknights. Individuals with inadequate nocturnal sleep typically “catch up” with longer sleep durations on days when they are free from social or occupational demands or on vacations.

Narcolepsy: As in hypersomnolence disorder, individuals with narcolepsy have chronic sleepiness, but several clinical and laboratory findings help distinguish the disorders. In contrast to those with hypersomnolence disorder, individuals with narcolepsy tend to sleep 7–8 hours each day and generally feel refreshed on waking in the morning. Individuals with narcolepsy generally feel more alert after a 15- to 20-minute nap, whereas those with hypersomnolence disorder tend to take longer naps, have trouble waking from naps, and do not feel alert afterward.

Fatigue: Hypersomnolence disorder should be distinguished from tiredness related to fatigue that may be a symptom of another mental disorder (e.g., generalized anxiety disorder) or medical condition (e.g., chronic fatigue syndrome). Unlike hypersomnolence, tiredness is not necessarily relieved by increased sleep and is unrelated to sleep quantity or quality.

Hypersomnia as a symptom of another mental disorder: Hypersomnolence disorder must
be distinguished from hypersomnolence occurring as a symptom of another mental disorder (e.g., major depressive episode, especially episodes with atypical features) or medical condition (e.g.,
certain cancers, multiple sclerosis). If the predominant complaint of excessive sleepiness is adequately explained by another mental disorder or medical condition, then an additional diagnosis of hypersomnolence disorder is not warranted. However, if the hypersomnolence is not adequately explained by a comorbid mental disorder or medical condition (e.g., the severity and nature of the hypersomnolence far exceed what would be expected with the mental disorder or medical condition), an additional diagnosis of hypersomnolence disorder is warranted.Comorbid Disorders
Many individuals with hypersomnolence disorder have symptoms of depression that may meet criteria for a depressive disorder. This presentation may be related to the psychosocial consequences of persistent increased sleep need. More than half of individuals with hypersomnolence disorder have attention-deficit/hyperactivity disorder symptoms. Individuals with hypersomnolence disorder are also at risk for substance-related disorders, particularly related to self-medication with stimulants.←

Narcolepsy Diagnostic Criteria
A. Recurrent periods of an irrepressible need to sleep, lapsing into sleep, or napping occurring within the same day. These must have been occurring at least three times per week over the past 3 months.
B. The presence of at least one of the following:
::::::::::::::1. Episodes of cataplexy, defined as either (a) or (b), occurring at least a few times per month:
:::::::::::::::::::::::a. In individuals with long-standing disease, brief (seconds to minutes) episodes of sudden bilateral loss of muscle tone with maintained consciousness that are precipitated by laughter or joking.
:::::::::::::::::::::::b. In individuals within 6 months of onset, spontaneous grimaces or jaw-opening episodes with tongue thrusting or a global hypotonia, without any obvious emotional triggers.
::::::::::::::2. Hypocretin deficiency.
::::::::::::::3. Nocturnal sleep polysomnography showing rapid eye movement (REM) sleep latency less than or equal to 15 minutes, or a multiple sleep latency test showing a mean sleep latency less than or equal to 8 minutes and two or more sleep-onset REM periods.Differential Diagnoses
Hypersomnolence Disorder
Sleep deprivation: Hypersomnolence disorder (also known as idiopathic hypersomnia) and narcolepsy are similar with respect to the presence of chronic daytime sleepiness, age at onset
(typically adolescence or early adulthood), and stable course over time, but can be distinguished
based on distinctive clinical and laboratory features. Individuals with hypersomnolence disorder
typically have longer and less disrupted nocturnal sleep, greater difficulty awakening, more persistent daytime sleepiness (as opposed to more discrete “sleep attacks” in narcolepsy), longer and less refreshing daytime sleep episodes, and little or no dreaming during daytime naps.

Major Depressive Disorder: Excessive daytime sleepiness is a common complaint of both individuals with major depression and individuals with narcolepsy. The presence of cataplexy (which is not a feature of major depressive disorder) along with the severity of excessive daytime sleepiness indicates a diagnosis of NT1 rather than major depressive disorder.

Functional Neurological Symptom Disorder (with Pseudocataplexy): Individuals with functional neurological symptom disorder can present with weakness that may raise questions of cataplexy. However, in functional neurological symptom disorder, the weakness is often long-lasting, has unusual triggers, and can result in frequent falls. Home video recordings and video during sleep studies can be helpful to distinguish this condition from true cataplexy. The weakness is usually generalized in pseudocataplexy, without partial attacks.

Atonic seizures: Atonic seizures, a type of seizure that causes sudden loss of muscle strength, must be distinguished from cataplexy. Atonic seizures are not commonly triggered by emotions and tend to manifest as abrupt falls rather than the slower “melting” quality of cataplexy. Atonic seizures usually occur in individuals with additional seizure types and have distinct signatures on
the electroencephalogram.Comorbid Disorders
Medical and psychiatric comorbidities are common among individuals with narcolepsy and include obesity, bruxism, enuresis, mood disorders, and ADHD. Rapid weight gain is common in young children with a sudden disease onset. Parasomnias (e.g., sleepwalking, REM sleep behavior disorder), obstructive sleep apnea, restless legs syndrome, and periodic limb movements are common in individuals who develop narcolepsy. Comorbid sleep apnea should be considered if there is a sudden aggravation of preexisting narcolepsy.←

Circadian Rhythm Sleep-Wake Disorders Diagnostic Criteria
A. A persistent or recurrent pattern of sleep disruption that is primarily due to an alteration of the circadian system or to a misalignment between the endogenous circadian rhythm and the sleep-wake schedule required by an individual’s physical environment or social or professional schedule.
B. The sleep disruption leads to excessive sleepiness or insomnia, or both.
C. The sleep disturbance causes clinically significant distress or impairment in social, occupational, and other important areas of functioning.
:
Delayed sleep phase type: A pattern of delayed sleep onset and awakening times, with an inability to fall asleep and awaken at a desired or conventionally acceptable earlier time.
Advanced sleep phase type: A pattern of advanced sleep onset and awakening times, with an inability to remain awake or asleep until the desired or conventionally acceptable later sleep or wake times.
Irregular sleep-wake type: A temporally disorganized sleep-wake pattern, such that the timing of
sleep and wake periods is variable throughout the 24-hour period.
Non-24-hour sleep-wake type: A pattern of sleepwake cycles that is not synchronized to the 24-hour environment, with a consistent daily drift (usually to later and later times) of sleep onset and wake times.
Shift work type: Insomnia during the major sleep period and/or excessive sleepiness (including inadvertent sleep) during the major awake period associated with a shift work schedule (i.e., requiring unconventional work hours).←

Non–REM Sleep Arousal Disorders Diagnostic Criteria
A. Recurrent episodes of incomplete awakening from sleep, usually occurring during the first third of the major sleep episode, accompanied by either one of the following:
::::::::::::::1. Sleepwalking: Repeated episodes of rising from bed during sleep and walking about. While sleepwalking, the individual has a blank, staring face; is relatively unresponsive to the efforts of others to communicate with him or her; and can be awakened only with great difficulty.
::::::::::::::2. Sleep terrors: Recurrent episodes of abrupt terror arousals from sleep, usually beginning with a panicky scream. There is intense fear and signs of autonomic arousal, such as mydriasis, tachycardia, rapid breathing, and sweating, during each episode. There is relative unresponsiveness to efforts of others to comfort the individual during the episodes.
B. No or little (e.g., only a single visual scene) dream imagery is recalled.
C. Amnesia for the episodes is present.
D. The episodes cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance.
F. Coexisting mental disorders and medical conditions do not explain the episodes of sleepwalking or sleep terrors.Associated Features
Sleepwalking episodes can include a wide variety of behaviors. Episodes may begin with confusion: the individual may simply sit up in bed, look about, or pick at the blanket or sheet. This behavior then becomes progressively complex. The individual may actually leave the bed and walk into closets, out of the room, and even out of buildings. Individuals may use the bathroom, eat, talk, or engage in more complex behaviors. Running and frantic attempts to escape some apparent threat can also occur. Most behaviors during sleepwalking episodes are routine and of low complexity. However, cases of unlocking doors and even operating machinery (driving an automobile) have been reported. Sleepwalking can also include inappropriate behavior (e.g., commonly, urinating in a closet or wastebasket). Most episodes last for several minutes to a half hour but may be more protracted. Inasmuch as sleep is a state of relative analgesia, painful injuries sustained during sleepwalking may not be appreciated until awakening after the fact.

There are two “specialized” forms of sleepwalking: sleep-related eating behavior and sleep-related sexual behavior (sexsomnia or sleep sex). Individuals with sleep-related eating experience unwanted recurrent episodes of eating with varying degrees of amnesia, ranging from no awareness to full awareness without the ability to avoid or stop eating. During these episodes, inappropriate foods or even nonfood items (i.e., candy wrappers, small food boxes, or even small toys) may be ingested. Individuals with sleep-related eating disorder may find evidence of their eating only the next morning. In sexsomnia, varying degrees of sexual activity (e.g., masturbation, fondling, groping, sexual intercourse) occur as complex behaviors arising from sleep without conscious awareness. This condition is more common in males and may result in serious interpersonal relationship problems or medicolegal consequences.

During a typical episode of sleep terrors, there is often a sense of overwhelming dread, with a compulsion to escape. Although fragmentary vivid dream images may occur, a storylike dream sequence (as in nightmares) is not reported. Most commonly, the individual does not awaken fully, but returns to sleep and has amnesia for the episode on awakening the next morning. Usually only one episode will occur on any one night. Occasionally, several episodes may occur at intervals throughout the night. These events rarely arise during daytime naps.Differential Diagnoses
Nightmare Disorder: In contrast to individuals with NREM sleep arousal disorders, individuals
with nightmare disorder typically awaken easily and completely, report vivid storylike dreams accompanying the episodes, and tend to have episodes later in the night. NREM sleep arousal disorders occur during NREM sleep, whereas nightmares usually occur during REM sleep. Parents of children with NREM sleep arousal disorders may misinterpret reports of fragmentary imagery as nightmares.

Dissociative Amnesia, with dissociative fugue: Dissociative fugue may be extremely difficult to
distinguish from sleepwalking. Unlike all other parasomnias, nocturnal dissociative fugue arises
from a period of wakefulness during sleep, rather than precipitously from sleep without intervening wakefulness. A history of recurrent childhood physical or sexual abuse is usually present (but may be difficult to obtain).Comorbid Disorders
Typically, sleepwalking in both children and adults is not associated with significant mental disorders. However, in adults, there is an association between sleepwalking and major depressive episodes and obsessive-compulsive disorder. Children or adults with sleep terrors may have elevated scores for depression and anxiety on personality inventories.←

Nightmare Disorder Diagnostic Criteria
A. Repeated occurrences of extended, extremely dysphoric, and well-remembered dreams that usually involve efforts to avoid threats to survival, security, or physical integrity and that generally occur during the second half of the major sleep episode.
B. On awakening from the dysphoric dreams, the individual rapidly becomes oriented and alert.
C. The sleep disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The nightmare symptoms are not attributable to the physiological effects of a substance.
E. Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of dysphoric dreams.Associated Features
Nightmares are typically lengthy, elaborate, story-like sequences of dream imagery that seem real and that incite anxiety, fear, or other dysphoric emotions. Nightmare content typically focuses on attempts to avoid or cope with imminent danger but may involve themes that evoke other negative emotions. Nightmares occurring after traumatic experiences may replicate the threatening situation, but most do not. On awakening, nightmares are well remembered and can be described in detail.

Nightmares usually terminate with awakening and rapid return of full alertness. However, the dysphoric emotions may persist into wakefulness and contribute to difficulty returning to sleep and lasting daytime distress. Some nightmares, known as “bad dreams,” may not induce awakening and are recalled only later. If nightmares occur during sleep-onset REM periods, the dysphoric emotion is frequently accompanied by an awakening and being unable to move voluntarily (sleep paralysis), which may also occur in isolation without a preceding dream or nightmare.Differential Diagnoses
Sleep terrors: Both nightmare disorder and sleep terror disorder include awakenings or partial awakenings with fearfulness and autonomic activation, but the two disorders can be readily differentiated. Nightmares typically occur later in the night, during REM sleep, and produce vivid, story-like, and clearly recalled dreams; mild autonomic arousal; and complete awakenings. Sleep terrors typically produce either no dream recall or images without an elaborate story-like quality. Sleep terrors are thought to be caused by partial awakenings intermixed with persisting sleep, with clinical manifestations of confusion, disorientation, and only partial responsiveness, and often with substantial autonomic arousal. There is usually amnesia for the event in the morning.

PTSD or Acute Stress Disorder: Nightmares in which the content or affect of the dream is related to a traumatic event may be a component of PTSD or acute stress disorder. An additional diagnosis of nightmare disorder may be warranted if the severity or frequency of the nightmares necessitates independent clinical attention.Comorbid Disorders
Nightmares may be comorbid with several medical conditions, including coronary heart disease, cancer, parkinsonism, and pain, and can accompany medical treatments, such as hemodialysis, or withdrawal from medications or substances of abuse. Nightmares frequently co-occur with other mental disorders, including PTSD, acute stress disorder, insomnia disorder, REM sleep behavior disorder, and psychotic, mood, anxiety, adjustment, and personality disorders, as well as with grief during bereavement. A concurrent nightmare disorder diagnosis should only be considered when
independent clinical attention is warranted.←

Restless Legs Syndrome Diagnostic Criteria
A. An urge to move the legs, usually accompanied by or in response to uncomfortable and unpleasant sensations in the legs, characterized by all of the following:
::::::::::::::1. The urge to move the legs begins or worsens during periods of rest or inactivity.
::::::::::::::2. The urge to move the legs is partially or totally relieved by movement.
::::::::::::::3. The urge to move the legs is worse in the evening or at night than during the day, or occurs only in the evening or at night.
B. The symptoms in Criterion A occur at least three times per week and have persisted for at least 3 months.
C. The symptoms in Criterion A are accompanied by significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning.
D. The symptoms in Criterion A are not attributable to another mental disorder or medical condition and are not better explained by a behavioral condition.
E. The symptoms are not attributable to the physiological effects of a drug of abuse or medication.Associated Features
Frequent movements of the legs occur in an effort to relieve the uncomfortable sensations. Although symptoms can occur during the daytime, they commonly occur in the late afternoon or evening hours, and in some individuals, symptoms occur only in the evening or night. Symptoms are often most severe at night when the individual is at rest, such as sitting or lying in bed. Evening worsening occurs independently of any differences in activity.

Periodic leg movements in sleep (PLMS) can serve as corroborating evidence for RLS, with up to 90% of individuals diagnosed with RLS demonstrating PLMS when recordings are taken over multiple nights. Periodic leg movements during wakefulness are also supportive of an RLS diagnosis. Reports of difficulty initiating and maintaining sleep and of excessive daytime sleepiness substantiate a diagnosis of RLS.Differential Diagnoses
The most important conditions in the differential diagnosis of RLS are leg cramps, positional discomfort, arthralgias/arthritis, myalgias, positional ischemia (numbness), leg edema, peripheral neuropathy, radiculopathy, and habitual foot tapping. Muscle cramps, relief with a single postural shift, limitation to joints, soreness to palpation (myalgias), and other abnormalities on physical examination are not characteristic of RLS. Unlike RLS, nocturnal leg cramps do not typically manifest with the desire to move the limbs nor are there frequent limb movements. Less common conditions to be differentiated from RLS include neuroleptic-induced akathisia, myelopathy, symptomatic venous insufficiency, peripheral artery disease, eczema, other orthopedic problems, and anxiety-induced restlessness. Worsening at night and periodic limb movements are more common in RLS than in medication-induced akathisia or peripheral neuropathy.Comorbid Disorders
RLS is associated with higher rates of depression, generalized anxiety disorder, panic disorder, and posttraumatic stress disorder. The main medical condition comorbid with RLS is cardiovascular disease. There may be an association with numerous other medical conditions, including hypertension, migraine, Parkinson’s disease, multiple sclerosis, peripheral neuropathy, diabetes mellitus, fibromyalgia, osteoporosis, obesity, thyroid disease, and cancer, as well as other sleep disorders including narcolepsy and obstructive sleep apnea.←

Gender Dysphoria Diagnostic Criteria
A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least two of the following:
::::::::::::::1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics.
::::::::::::::2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender.
::::::::::::::3. A strong desire for the primary and/or secondary sex characteristics of the other gender.
::::::::::::::4. A strong desire to be of an alternative gender from one's assigned gender.
::::::::::::::5. A strong desire to be treated as an alternative gender from one's assigned gender.
::::::::::::::6. A strong conviction that one has the typical feelings and reactions of an alternative gender from one's assigned gender.
B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.Associated Features
In adolescents and adults with gender dysphoria, the discrepancy between experienced gender and physical sex characteristics is often, but not always, accompanied by a desire to be rid of primary and/or secondary sex characteristics and/or a strong desire to acquire some primary and/or secondary sex characteristics of another gender. To varying degrees, older adolescents and adults with gender dysphoria may adopt the behavior, clothing, and mannerisms of their experienced gender. They feel uncomfortable being regarded by others, or functioning in society, as members of their assigned gender. Some adults and adolescents may have a strong desire to be of a different gender and treated as such, and they may have an inner certainty to feel and respond as their experienced gender without seeking medical treatment to alter body characteristics. They may find other ways to resolve the incongruence between experienced/expressed and assigned gender by partially living in the desired role or by adopting a gender role neither conventionally male nor conventionally female.

In children, adolescents, and adults with gender dysphoria, an overrepresentation of autism spectrum traits has been observed. Also, individuals with autism spectrum disorder are more likely to exhibit gender diversity.Differential Diagnoses
Nonconformity to gender roles: Gender dysphoria should be distinguished from simple nonconformity to stereotypical gender role behavior by the strong desire to be of another gender
than the assigned one and by the extent and pervasiveness of gender-variant activities and interests. The diagnosis is not meant to merely describe nonconformity to stereotypical gender role behavior. Given the increased openness of gender-diverse expressions by individuals across the entire range of the transgender spectrum, it is important that the clinical diagnosis be limited to those individuals whose distress and impairment meet the specified criteria.

Body Dysmorphic Disorder: An individual with body dysmorphic disorder focuses on the alteration or removal of a specific body part because it is perceived as abnormally formed, not because it represents a repudiated assigned gender. When an individual’s presentation meets criteria for both gender dysphoria and body dysmorphic disorder, both diagnoses can be given. Individuals wishing to have a healthy limb amputated (termed by some body integrity identity disorder) because it makes them feel more “complete” usually do not wish to change gender, but rather desire to live as an amputee or a disabled person.Comorbid Disorders
RLS is associated with higher rates of depression, generalized anxiety disorder, panic disorder, and posttraumatic stress disorder. The main medical condition comorbid with RLS is cardiovascular disease. There may be an association with numerous other medical conditions, including hypertension, migraine, Parkinson’s disease, multiple sclerosis, peripheral neuropathy, diabetes mellitus, fibromyalgia, osteoporosis, obesity, thyroid disease, and cancer, as well as other sleep disorders including narcolepsy and obstructive sleep apnea.←

Oppositional Defiant Disorder Diagnostic Criteria
A. A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling.
:::::::Angry/Irritable Mood
::::::::::::::1. Often loses temper.
::::::::::::::2. Is often touchy or easily annoyed.
::::::::::::::3. Is often angry and resentful.
:::::::Argumentative/Defiant Behavior
::::::::::::::4. Often argues with authority figures or, for children and adolescents, with adults.
::::::::::::::5. Often actively defies or refuses to comply with requests from authority figures or with rules.
::::::::::::::6. Often deliberately annoys others.
::::::::::::::7. Often blames others for their mistakes or misbehavior.
:::::::Vindictiveness
::::::::::::::8. Has been spiteful or vindictive at least twice within the past 6 months.
B. The disturbance in behavior is associated with distress in the individual or others in their immediate social context, or it impacts negatively on social, educational, occupational, or other important areas of functioning.
C. The behaviors do not occur exclusively during the course of a psychotic, substance use, depressive, or bipolar disorder. Also, the criteria are not met for disruptive mood dysregulation disorder.Associated Features
The symptoms of the disorder often are part of a pattern of problematic interactions with others. Furthermore, individuals with this disorder typically do not regard themselves as angry, oppositional, or defiant. Instead, they often justify their behavior as a response to unreasonable demands or circumstances. Thus, it can be difficult to disentangle the relative contribution of the individual with the disorder to the problematic interactions he or she experiences. For example, children with oppositional defiant disorder may have experienced a history of hostile parenting, and it is often impossible to determine if the child’s behavior caused the parents to act in a more hostile manner toward the child, if the parents’ hostility led to the child’s problematic behavior, or if there was some combination of both.Differential Diagnoses
Conduct Disorder: Conduct disorder and oppositional defiant disorder are both related to conduct
problems that bring the individual in conflict with adults and other authority figures (e.g., teachers, work supervisors). The behaviors of oppositional defiant disorder are typically of a less severe nature than those of conduct disorder and do not include aggression toward people or animals, destruction of property, or a pattern of theft or deceit. However, evidence suggests that oppositional defiant disorder is associated with equivalent or even greater levels of impairment than conduct disorder. Furthermore, oppositional defiant disorder includes problems of emotion dysregulation (i.e., angry and irritable mood) that are not included in the definition of conduct
disorder.

ADHD: ADHD is often comorbid with oppositional defiant disorder. To make the additional diagnosis of oppositional defiant disorder, it is important to determine that the individual’s failure to conform to requests of others is not solely in situations that demand sustained effort and attention or demand that the individual sit still.Comorbid Disorders
Rates of oppositional defiant disorder are much higher in samples of children, adolescents, and adults with ADHD, and this may be the result of shared temperamental risk factors. Also, oppositional defiant disorder often precedes conduct disorder, although this appears to be most common in children with the childhood-onset subtype. Individuals with oppositional defiant disorder are also at increased risk for anxiety disorders and major depressive disorder, and this seems largely attributable to the presence of the angry-irritable mood symptoms.←

Intermittent Explosive Disorder Diagnostic Criteria
A. Recurrent behavioral outbursts representing a failure to control aggressive impulses as manifested by either of the following:
::::::::::::::1. Verbal aggression (e.g., temper tantrums, tirades, verbal arguments or fights) or physical aggression toward property, animals, or other individuals, occurring twice weekly, on average, for a period of 3 months. The physical aggression does not result in damage or destruction of property and does not result in physical injury to animals or other individuals.
::::::::::::::2. Three behavioral outbursts involving damage or destruction of property and/or physical assault involving physical injury against animals or other individuals occurring within a 12-month period.
B. The magnitude of aggressiveness expressed during the recurrent outbursts is grossly out of proportion to the provocation or to any precipitating psychosocial stressors.
C. The recurrent aggressive outbursts are not premeditated (i.e., they are impulsive and/or anger-based) and are not committed to achieve some tangible objective.
D. The recurrent aggressive outbursts cause either marked distress in the individual or impairment in occupational or interpersonal functioning, or are associated with financial or legal consequences.
E. Chronological age is at least 6 years.
F. The recurrent aggressive outbursts are not better explained by another mental disorder (e.g., major depressive disorder, bipolar disorder, disruptive mood dysregulation disorder, a psychotic disorder, antisocial personality disorder, borderline personality disorder) and are not attributable to another medical condition or to the physiological effects of a substance. For children ages 6–18 years, aggressive behavior that occurs as part of an adjustment disorder should not be considered for this diagnosis.Differential Diagnoses
A diagnosis of intermittent explosive disorder should not be made when Criteria A1 and/or A2 are only met during an episode of another mental disorder (e.g., major depressive disorder, bipolar disorder, psychotic disorder), or when impulsive aggressive outbursts are attributable to another medical condition or to the physiological effects of a substance or medication. This diagnosis also should not be made, particularly in children and adolescents ages 6–18 years, when the impulsive aggressive outbursts occur in the context of an adjustment disorder.

Antisocial and Borderline Personality Disorders: Individuals with antisocial personality disorder or borderline personality disorder often display recurrent, problematic impulsive aggressive outbursts. However, the level of impulsive aggression in individuals with antisocial personality disorder or borderline personality disorder is lower than that in individuals with intermittent explosive disorder.

ADHD, Conduct Disorder, Oppositional Defiant Disorder, or Autism Spectrum Disorder: Individuals with any of these childhood-onset disorders may exhibit impulsive aggressive
outbursts. Individuals with ADHD are typically impulsive and, as a result, may also exhibit impulsive aggressive outbursts. While individuals with conduct disorder can exhibit impulsive aggressive outbursts, the form of aggression characterized by the diagnostic criteria is proactive and predatory. Aggression in oppositional defiant disorder is typically characterized by temper tantrums and verbal arguments with authority figures, whereas impulsive aggressive outbursts in intermittent explosive disorder are in response to a broader array of provocation and include physical assault. The level of impulsive aggression in individuals with a history of one or more of these disorders has been reported as lower than that in comparable individuals whose symptoms also meet intermittent explosive disorder Criteria A through E. Accordingly, if Criteria A through E are also met, and the impulsive aggressive outbursts warrant independent clinical attention, a diagnosis of intermittent explosive disorder may be given.Comorbid Disorders
Depressive disorders, anxiety disorders, posttraumatic stress disorder, bulimia nervosa, binge-eating disorder, and substance use disorders are most commonly comorbid with intermittent explosive disorder in community samples. In addition, individuals with antisocial personality disorder or borderline personality disorder, and individuals with a history of disorders with disruptive behaviors (e.g., ADHD, conduct disorder, oppositional defiant disorder), are at greater risk for comorbid intermittent explosive disorder.←

Conduct Disorder Diagnostic Criteria
A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least three of the following 15 criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months:
:::::::Aggression to People and Animals
::::::::::::::1. Often bullies, threatens, or intimidates others.
::::::::::::::2. Often initiates physical fights.
::::::::::::::3. Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun).
::::::::::::::4. Has been physically cruel to people.
::::::::::::::5. Has been physically cruel to animals.
::::::::::::::6. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery).
::::::::::::::7. Has forced someone into sexual activity.
:::::::Destruction of Property
::::::::::::::8. Has deliberately engaged in fire setting with the intention of causing serious damage.
::::::::::::::9. Has deliberately destroyed others’ property (other than by fire setting).
:::::::Deceitfulness or Theft
::::::::::::::10. Has broken into someone else’s house, building, or car.
::::::::::::::11. Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others).
::::::::::::::12. Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery).
:::::::Serious Violations of Rules
::::::::::::::13. Often stays out at night despite parental prohibitions, beginning before age 13 years.
::::::::::::::14. Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period.
::::::::::::::15. Is often truant from school, beginning before age 13 years.
B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
C. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.Associated Features
Especially in ambiguous situations, aggressive individuals with conduct disorder frequently misperceive the intentions of others as more hostile and threatening than is the case and respond with aggression that they then feel is reasonable and justified. Personality features of trait negative emotionality and poor self-control, including poor frustration tolerance, irritability, temper outbursts, suspiciousness, insensitivity to punishment, thrill seeking, and recklessness, frequently co-occur with conduct disorder. Substance misuse is often an associated feature, particularly in adolescent
girls.

Conduct disorder may be diagnosed in adults; however, symptoms of conduct disorder usually emerge in childhood or adolescence, and onset is rare after age 16 years. The course of conduct disorder after onset is variable. In a majority of individuals, the disorder remits by adulthood. Many individuals with conduct disorder—particularly those with adolescent-onset type and those with few and milder symptoms—achieve adequate social and occupational adjustment as adults. However, the childhood-onset type predicts a worse prognosis and an increased risk of criminal behavior, conduct disorder, and substance-related disorders in adulthood.Differential Diagnoses
Oppositional Defiant Disorder: Conduct disorder and oppositional defiant disorder are both related to symptoms that bring the individual in conflict with adults and other authority figures. The behaviors of oppositional defiant disorder are typically of a less severe nature than those of individuals with conduct disorder and do not include aggression toward people or animals, destruction of property, or a pattern of theft or deceit. Furthermore, oppositional defiant disorder includes problems of emotion dysregulation (i.e., angry and irritable mood) that are not included in the definition of conduct disorder. When criteria are met for both oppositional defiant disorder and conduct disorder, both diagnoses can be given.

Depressive and Bipolar Disorders: Irritability, aggression, and conduct problems can occur in
children or adolescents with major depressive disorder, bipolar disorder, or disruptive mood dysregulation disorder. The behavioral problems associated with these mood disorders can usually be distinguished from the pattern of conduct problems seen in conduct disorder based on their course. Specifically, individuals with conduct disorder will display substantial levels of aggressive or nonaggressive conduct problems during periods in which there is no mood disturbance, either historically (i.e., a history of conduct problems predating the onset of the mood disturbance) or concurrently (i.e., display of some conduct problems that are premeditated and do not occur during periods of intense emotional arousal). In those cases in which criteria for conduct disorder and a mood disorder are met, both diagnoses can be given.

Intermittent Explosive Disorder: Both conduct disorder and intermittent explosive disorder involve high rates of aggression. However, the aggression in individuals with intermittent explosive disorder is limited to impulsive aggression and is not premeditated, and it is not committed in order to achieve some tangible objective (e.g., money, power, intimidation). Also, the definition of intermittent explosive disorder does not include the non-aggressive symptoms of conduct disorder. If criteria for both disorders are met, the diagnosis of intermittent explosive disorder should be given only when the recurrent impulsive aggressive outbursts warrant independent clinical attention.

Adjustment Disorder: The diagnosis of an adjustment disorder (with disturbance of conduct or
with mixed disturbance of emotions and conduct) should be considered if clinically significant conduct problems that do not meet the criteria for another specific disorder develop in clear association with the onset of a psychosocial stressor and do not resolve within 6 months of the termination of the stressor (or its consequences). Conduct disorder is diagnosed only when the conduct problems represent a repetitive and persistent pattern that is associated with impairment
in social, academic, or occupational functioning.Comorbid Disorders
ADHD and oppositional defiant disorder are both common in individuals with conduct disorder, and this comorbid presentation predicts worse outcomes. Individuals who show the personality features associated with antisocial personality disorder often violate the basic rights of others or violate major age-appropriate societal norms, and as a result their pattern of behavior often meets criteria for conduct disorder. Conduct disorder may also co-occur with one or more of the following mental disorders: specific learning disorder, anxiety disorders, depressive or bipolar disorders, and substance-related disorders. Academic achievement, particularly in reading and other verbal skills, is often below the level expected on the basis of age and intelligence and may justify the additional diagnosis of specific learning disorder or a communication disorder.←

Pyromania Diagnostic Criteria
A. Deliberate and purposeful fire setting on more than one occasion.
B. Tension or affective arousal before the act.
C. Fascination with, interest in, curiosity about, or attraction to fire and its situational contexts (e.g., paraphernalia, uses, consequences).
D. Pleasure, gratification, or relief when setting fires or when witnessing or participating in their aftermath.
E. The fire setting is not done for monetary gain, as an expression of sociopolitical ideology, to conceal criminal activity, to express anger or vengeance, to improve one’s living circumstances, in response to a delusion or hallucination, or as a result of impaired judgment.
F. The fire setting is not better explained by conduct disorder, a manic episode, or antisocial personality disorder.Associated Features
Individuals with pyromania may make considerable advance preparation for starting a fire. They may be indifferent to the consequences to life or property caused by the fire, or they may derive satisfaction from the resulting property destruction. The behaviors may lead to property damage, legal consequences, or injury or loss of life to the fire setter or to others.Differential Diagnoses
Other causes of intentional fire setting: It is important to rule out other causes of fire setting before giving the diagnosis of pyromania. Intentional fire setting may occur for profit, sabotage, or revenge; to conceal a crime; to make a political statement (e.g., an act of terrorism or protest); or to attract attention or recognition (e.g., setting a fire in order to discover it and save the day). Fire setting may also occur as part of developmental experimentation in childhood (e.g., playing with matches, lighters, or fire).Comorbid Disorders
There appears to be a high co-occurrence of substance use disorders, gambling disorder, depressive and bipolar disorders, and other disruptive, impulse-control, and conduct disorders with pyromania.←

Kleptomania Diagnostic Criteria
A. Recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value.
B. Increasing sense of tension immediately before committing the theft.
C. Pleasure, gratification, or relief at the time of committing the theft.
D. The stealing is not committed to express anger or vengeance and is not in response to a delusion or a hallucination.
E. The stealing is not better explained by conduct disorder, a manic episode, or antisocial personality disorder.Associated Features
Individuals with kleptomania typically attempt to resist the impulse to steal, and they are aware that the act is wrong and senseless. The individual frequently fears being apprehended and often feels depressed or guilty about the thefts.Differential Diagnoses
Ordinary theft: Kleptomania should be distinguished from ordinary acts of theft or shoplifting.
Ordinary theft (whether planned or impulsive) is deliberate and is motivated by the usefulness of
the object or its monetary worth. Some persons, especially adolescents, may also steal on a dare, as an act of rebellion, or as a rite of passage. The diagnosis is not made unless other characteristic features of kleptomania are also present. Kleptomania is rare, whereas shoplifting is relatively common.

Antisocial Personality Disorder or Conduct Disorder: Antisocial personality disorder and conduct
disorder are distinguished from kleptomania by a general pattern of antisocial behavior.Comorbid Disorders
Kleptomania may be associated with compulsive buying as well as with depressive and bipolar disorders (especially major depressive disorder), anxiety disorders, eating disorders (particularly bulimia nervosa), personality disorders, substance use disorders (especially alcohol use disorder), and other disruptive, impulse-control, and conduct disorders.←

Paranoid Personality Disorder Diagnostic Criteria
A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
::::::::::::::1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving them.
::::::::::::::2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.
::::::::::::::3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against them.
::::::::::::::4. Reads hidden demeaning or threatening meanings into benign remarks or events.
::::::::::::::5. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights).
::::::::::::::6. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack.
::::::::::::::7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.
B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiological effects of another medical condition.Associated Features
Their excessive suspiciousness and hostility may be expressed in overt argumentativeness, in recurrent complaining, or by hostile aloofness. They display a labile range of affect, with hostile, stubborn, and sarcastic expressions predominating. Their combative and suspicious nature may elicit a hostile response in others, which then serves to confirm their original expectations.

Because individuals with paranoid personality disorder lack trust in others, they need to have a high degree of control over those around them. They are often rigid, critical of others, and unable to collaborate, although they have great difficulty accepting criticism themselves. They may blame others for their own shortcomings. Because of their quickness to counterattack in response to the threats they perceive around them, they may be litigious and frequently become involved in legal disputes. Individuals with this disorder seek to confirm their preconceived negative notions regarding people or situations they encounter, attributing malevolent motivations to others that are projections of their own fears. They may exhibit thinly hidden, unrealistic grandiose fantasies, are often attuned to issues of power and rank, and tend to develop negative stereotypes of others, particularly those from population groups distinct from their own.Differential Diagnoses
Other mental disorders with psychotic symptoms: Paranoid personality disorder can be distinguished from delusional disorder, persecutory type; schizophrenia; and a bipolar or depressive disorder with psychotic features because these disorders are all characterized by a period of persistent psychotic symptoms (e.g., delusions and hallucinations). For an additional diagnosis of paranoid personality disorder to be given, the personality disorder must have been present before the onset of psychotic symptoms and must persist when the psychotic symptoms are in remission.

Other personality disorders: Other personality disorders may be confused with paranoid personality disorder because they have certain features in common. It is therefore
important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to paranoid personality disorder, all can be diagnosed.
Paranoid personality disorder and schizotypal personality disorder share the traits of suspiciousness, interpersonal aloofness, and paranoid ideation, but schizotypal personality disorder also includes symptoms such as magical thinking, unusual perceptual experiences, and odd thinking and speech. Individuals with behaviors that meet criteria for schizoid personality disorder are often perceived as strange, eccentric, cold, and aloof, but they do not usually have prominent paranoid ideation. The tendency of individuals with paranoid personality disorder to react to minor stimuli with anger is also seen in borderline and histrionic personality disorders. However, these disorders are not necessarily associated with pervasive suspiciousness, and borderline personality disorder exhibits higher levels of impulsivity and self-destructive behavior. People with avoidant personality disorder may also be reluctant to confide in others, but more from fear of being embarrassed or found inadequate than from fear of others’ malicious intent. Although antisocial behavior may be present in some individuals with paranoid personality disorder, it is not usually motivated by a desire for personal gain or to exploit others as in antisocial personality disorder, but rather is more often attributable to a desire for revenge. Individuals with narcissistic personality disorder may occasionally display suspiciousness, social withdrawal, or alienation, but this derives primarily from fears of having their imperfections or flaws revealed.Comorbid Disorders
Particularly in response to stress, individuals with this disorder may experience very brief psychotic episodes (lasting minutes to hours). In some instances, paranoid personality disorder may appear as the premorbid antecedent of delusional disorder or schizophrenia. Individuals with paranoid personality disorder may develop major depressive disorder and may be at increased risk for agoraphobia and obsessive-compulsive disorder. Alcohol and other substance use disorders frequently occur. The most common co-occurring personality disorders appear to be schizotypal, schizoid, narcissistic, avoidant, and borderline.←

Schizoid Personality Disorder Diagnostic Criteria
A. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
::::::::::::::1. Neither desires nor enjoys close relationships, including being part of a family.
::::::::::::::2. Almost always chooses solitary activities.
::::::::::::::3. Has little, if any, interest in having sexual experiences with another person.
::::::::::::::4. Takes pleasure in few, if any, activities.
::::::::::::::5. Lacks close friends or confidants other than first-degree relatives.
::::::::::::::6. Appears indifferent to the praise or criticism of others.
::::::::::::::7. Shows emotional coldness, detachment, or flattened affectivity.
B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder and is not attributable to the physiological effects of another medical condition.Associated Features
Individuals with schizoid personality disorder may have particular difficulty expressing anger, even in response to direct provocation, which contributes to the impression that they lack emotion. Their lives sometimes seem directionless, and they may appear to “drift” in their goals. Such individuals often react passively to adverse circumstances and have difficulty responding appropriately to important life events. Because of their lack of social skills and lack of desire for sexual experiences, individuals with this disorder have few friendships, date infrequently, and often do not marry. Occupational functioning may be impaired, particularly if interpersonal involvement is required, but individuals with this disorder may do well when they work under conditions of social isolation.Differential Diagnoses
Other mental disorders with psychotic symptoms: Schizoid personality disorder can be distinguished from delusional disorder, schizophrenia, and a bipolar or depressive disorder with psychotic features because these disorders are all characterized by a period of persistent psychotic
symptoms (e.g., delusions and hallucinations). To give an additional diagnosis of schizoid personality disorder, the personality disorder must have been present before the onset of psychotic symptoms and must persist when the psychotic symptoms are in remission. When an individual has a persistent psychotic disorder (e.g., schizophrenia) that was preceded by schizoid personality disorder, schizoid personality disorder should also be recorded, followed by “premorbid” in parentheses.

Autism Spectrum Disorder: There may be great difficulty differentiating individuals with schizoid personality disorder from individuals with autism spectrum disorder, particularly with milder
forms of either disorder, as both include a seeming indifference to companionship with others.
However, autism spectrum disorder may be differentiated by stereotyped behaviors and interests.

Other personality disorders and personality traits: Other personality disorders may be confused with schizoid personality disorder because they have certain features in common. It is, therefore,
important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to schizoid personality disorder, all can be diagnosed.
Although characteristics of social isolation and restricted affectivity are common to schizoid, schizotypal, and paranoid personality disorders, schizoid personality disorder can be distinguished from schizotypal personality disorder by the lack of cognitive and perceptual distortions and from paranoid personality disorder by the lack of suspiciousness and paranoid ideation. The social isolation of schizoid personality disorder can be distinguished from that of avoidant personality disorder, which is attributable to fear of being embarrassed or found inadequate and excessive anticipation of rejection. In contrast, people with schizoid personality disorder have a more pervasive detachment and limited desire for social intimacy. Individuals with obsessive-compulsive personality disorder may also show an apparent social detachment stemming from devotion to work and discomfort with emotions, but they do have an underlying capacity for intimacy. Individuals who are “loners” or quite introverted may display personality traits that might be considered schizoid, consistent with the broader conceptualization of schizoid personality disorder as a disorder defined by pathological introversion/detachment. Only when these traits are inflexible and maladaptive and cause significant functional impairment or subjective distress do they constitute schizoid personality disorder.Comorbid Disorders
Particularly in response to stress, individuals with this disorder may experience very brief psychotic episodes (lasting minutes to hours). In some instances, schizoid personality disorder may appear as the premorbid antecedent of delusional disorder or schizophrenia. Individuals with this disorder may sometimes develop major depressive disorder. Schizoid personality disorder most often co-occurs with schizotypal, paranoid, and avoidant personality disorders.←

Schizotypal Personality Disorder Diagnostic Criteria
A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
::::::::::::::1. Ideas of reference (excluding delusions of reference).
::::::::::::::2. Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”; in children and adolescents, bizarre fantasies or preoccupations).
::::::::::::::3. Unusual perceptual experiences, including bodily illusions.
::::::::::::::4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped).
::::::::::::::5. Suspiciousness or paranoid ideation.
::::::::::::::6. Inappropriate or constricted affect.
::::::::::::::7. Behavior or appearance that is odd, eccentric, or peculiar.
::::::::::::::8. Lack of close friends or confidants other than first-degree relatives.
::::::::::::::9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.
B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder.Associated Features
Individuals with schizotypal personality disorder often have ideas of reference (i.e., incorrect interpretations of casual incidents and external events as having a particular and unusual meaning specifically for the person). These should be distinguished from delusions of reference, in which the beliefs are held with delusional conviction. These individuals may be superstitious or preoccupied with paranormal phenomena that are outside the norms of their subculture. They may feel that they have special powers to sense events before they happen or to read others’ thoughts. They may believe that they have magical control over others, which can be implemented directly (e.g., believing that their spouse’s taking the dog out for a walk is the direct result of thinking an hour earlier it should be done) or indirectly through compliance with magical rituals (e.g., walking past a specific object three times to avoid a certain harmful outcome). Perceptual alterations may be present (e.g., sensing that another person is present or hearing a voice murmuring their name). Their speech may include unusual or idiosyncratic phrasing and construction. It is often loose, digressive, or vague, but without actual derailment or incoherence. Responses can be either overly concrete or overly abstract, and words or concepts are sometimes applied in unusual ways (e.g., the individual may state that they were not “talkable” at work).Differential Diagnoses
Other mental disorders with psychotic symptoms: Schizotypal personality disorder can be distinguished from delusional disorder, schizophrenia, and a bipolar or depressive disorder with
psychotic features because these disorders are all characterized by a period of persistent psychotic symptoms (e.g., delusions and hallucinations). To give an additional diagnosis of schizotypal personality disorder, the personality disorder must have been present before the onset of psychotic symptoms and persist when the psychotic symptoms are in remission.

Neurodevelopmental Disorders: There may be great difficulty differentiating children with
schizotypal personality disorder from the heterogeneous group of solitary, odd children whose behavior is characterized by marked social isolation, eccentricity, or peculiarities of language and whose diagnoses would probably include milder forms of autism spectrum disorder or language communication disorders. Communication disorders may be differentiated by the primacy and severity of the disorder in language and by the characteristic features of impaired language found in a specialized language assessment. Milder forms of autism spectrum disorder are differentiated by the even greater lack of social awareness and emotional reciprocity and stereotyped behaviors and interests.

Other personality disorders: Schizotypal features during adolescence may be reflective of transient emotional turmoil rather than an enduring personality disorder. Other personality disorders may be confused with schizotypal personality disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to schizotypal personality disorder, all can be diagnosed.
Although paranoid and schizoid personality disorders may also be characterized by social detachment and restricted affect, schizotypal personality disorder can be distinguished from these two diagnoses by the presence of cognitive or perceptual distortions and marked eccentricity or oddness. Close relationships are limited in both schizotypal personality disorder and avoidant personality disorder; however, in avoidant personality disorder an active desire for relationships is constrained by a fear of rejection, whereas in schizotypal personality disorder there is a lack of desire for relationships and persistent detachment. Individuals with narcissistic personality disorder may also display suspiciousness, social withdrawal, or alienation, but in narcissistic personality disorder these qualities derive primarily from fears of having imperfections or flaws revealed. Individuals with borderline personality disorder may also have transient, psychotic-like symptoms, but these are usually more closely related to affective shifts in response to stress (e.g., intense anger, anxiety, disappointment) and are usually more dissociative (e.g., derealization, depersonalization). In contrast, individuals with schizotypal personality disorder are more likely to have enduring psychotic-like symptoms that may worsen under stress but are less likely to be invariably associated with pronounced affective symptoms. Although social isolation may occur in borderline personality disorder, it is usually secondary to repeated interpersonal failures due to angry outbursts and frequent mood shifts, rather than a result of a persistent lack of social contacts and desire for intimacy. Furthermore, individuals with schizotypal personality disorder do not usually demonstrate the impulsive or manipulative behaviors of the individual with borderline personality disorder. However, there is a high rate of co-occurrence between the two disorders, so that making such distinctions is not always feasible.Comorbid Disorders
Particularly in response to stress, individuals with this disorder may experience transient psychotic episodes (lasting minutes to hours), although they usually are insufficient in duration to warrant an additional diagnosis such as brief psychotic disorder or schizophreniform disorder. In some cases, clinically significant psychotic symptoms may develop that meet criteria for brief psychotic disorder, schizophreniform disorder, delusional disorder, or schizophrenia. There is considerable co-occurrence with schizoid, paranoid, avoidant, and borderline personality disorders.←

Antisocial Personality Disorder Diagnostic Criteria
A. A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by three (or more) of the following:
::::::::::::::1. Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.
::::::::::::::2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.
::::::::::::::3. Impulsivity or failure to plan ahead.
::::::::::::::4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
::::::::::::::5. Reckless disregard for safety of self or others.
::::::::::::::6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.
::::::::::::::7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.
B. The individual is at least age 18 years.
C. There is evidence of conduct disorder with onset before age 15 years.
D. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder.Associated Features
Individuals with antisocial personality disorder frequently lack empathy and tend to be callous, cynical, and contemptuous of the feelings, rights, and sufferings of others. They may have an inflated and arrogant self-appraisal and may be excessively opinionated, self-assured, or cocky. Some antisocial individuals may display a glib, superficial charm and can be quite voluble and verbally facile.

These individuals may also be irresponsible and exploitative in their sexual relationships. They may have a history of many sexual partners and may never have sustained a monogamous relationship. They may be irresponsible as parents, as evidenced by malnutrition of a child, an illness in the child resulting from a lack of minimal hygiene, a child’s dependence on neighbors or nonresident relatives for food or shelter, a failure to arrange for a caretaker for a young child when the individual is away from home, or repeated squandering of money required for household necessities.Differential Diagnoses
Conduct Disorder: The diagnosis of antisocial personality disorder is not given to individuals younger than 18 years and is given only if there is evidence of conduct disorder before age 15 years. For individuals older than 18 years, a diagnosis of conduct disorder is given only if the criteria for antisocial personality disorder are not met.

Other personality disorders: Other personality disorders may be confused with antisocial personality disorder because they have certain features in common. It is therefore important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to antisocial personality disorder, all can be diagnosed.
Individuals with antisocial
personality disorder and narcissistic personality disorder share a tendency to be tough-minded,
glib, superficial, exploitative, and lack empathy. However, narcissistic personality disorder does not include characteristics of impulsivity, aggression, and deceit. In addition, individuals with antisocial personality disorder may not be as needy of the admiration and envy of others, and persons with narcissistic personality disorder usually lack the history of conduct disorder in childhood or criminal behavior in adulthood. Individuals with antisocial personality disorder and histrionic personality disorder share a tendency to be impulsive, superficial, excitement seeking, reckless, seductive, and manipulative, but persons with histrionic personality disorder tend to be more exaggerated in their emotions and do not characteristically engage in antisocial behaviors. Individuals with histrionic and borderline personality disorders are manipulative to gain nurturance, whereas those with antisocial personality disorder are manipulative to gain profit, power, or some other material gratification. Individuals with antisocial personality disorder tend to be less emotionally unstable and more aggressive than those with borderline personality disorder. Although antisocial behavior may be present in some individuals with paranoid personality disorder, it is not usually motivated by a desire for personal gain or to exploit others as in antisocial personality disorder, but rather is
more often attributable to a desire for revenge.Comorbid Disorders
Individuals with antisocial personality disorder may also experience dysphoria, including complaints of tension, inability to tolerate boredom, and depressed mood. They may have associated anxiety disorders, mood disorders, substance use disorders, somatic symptom disorder, and gambling disorder. Individuals with antisocial personality disorder also often have personality features that meet criteria for other personality disorders, particularly borderline, histrionic, and narcissistic personality disorders. The likelihood of developing antisocial personality disorder in adult life is increased if the individual experienced childhood onset of conduct disorder (before age 10 years) and accompanying ADHD.←

Borderline Personality Disorder Diagnostic Criteria
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Frantic efforts to avoid real or imagined abandonment. Do not include suicidal or self-mutilating behavior covered in Criterion 5.
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Do not include suicidal or self-mutilating behavior covered in Criterion 5.
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.Associated Features
The perception of impending separation or rejection, or the loss of external structure, can lead to profound changes in self-image, affect, cognition, and behavior. These individuals are very sensitive to environmental circumstances. They experience intense abandonment fears and inappropriate anger even when faced with a realistic time-limited separation or when there are unavoidable changes in plans (e.g., sudden despair in reaction to a clinician’s announcing the end of the hour; panic or fury when someone important to them is just a few minutes late or must cancel an appointment). They may believe that this “abandonment” implies they are “bad.” These abandonment fears are related to an intolerance of being alone and a need to have other people with them. Their frantic efforts to avoid abandonment may include impulsive actions such as self-mutilating or suicidal behaviors.

They may idealize potential caregivers or lovers at the first or second meeting, demand to spend a lot of time together, and share the most intimate details early in a relationship. However, they may switch quickly from idealizing other people to devaluing them, feeling that the other person does not care enough, does not give enough, or is not “there” enough. These individuals can empathize with and nurture other people, but only with the expectation that the other person will “be there” in return to meet their own needs on demand. These individuals are prone to sudden and dramatic shifts in their view of others, who may alternatively be seen as beneficent supports or as cruelly punitive. Such shifts often reflect disillusionment with a caregiver whose nurturing qualities had been idealized or whose rejection or abandonment is expected.

There are sudden and dramatic shifts in self-image (e.g., suddenly changing from the role of a needy supplicant for help to that of a righteous avenger of past mistreatment). Although they usually have a self-image that is based on the feeling of being bad or evil, individuals with this disorder may at times have feelings that they do not exist at all. This can be both painful and frightening to those with this disorder. Such experiences usually occur in situations in which the individual feels a lack of a meaningful relationship, nurturing, and support. These individuals may show worse performance in unstructured work or school situations. This lack of a full and enduring identity makes it difficult for the individual with borderline personality disorder to identify maladaptive patterns of behavior and can lead to repetitive patterns of troubled relationships.

They may display extreme sarcasm, enduring bitterness, or verbal outbursts. The anger is often elicited when a caregiver or lover is seen as neglectful, withholding, uncaring, or abandoning. Such expressions of anger are often followed by shame and guilt and contribute to the feeling they have of being evil. During periods of extreme stress, transient paranoid ideation or dissociative symptoms (e.g., depersonalization) may occur, but these are generally of insufficient severity or duration to warrant an additional diagnosis. These episodes occur most frequently in response to
a real or imagined abandonment. Symptoms tend to be transient, lasting minutes or hours. The
real or perceived return of the caregiver’s nurturance may result in a remission of symptoms.

Individuals with borderline personality disorder may have a pattern of undermining themselves at the moment a goal is about to be realized (e.g., dropping out of school just before graduation; regressing severely after a discussion of how well therapy is going; destroying a good relationship just when it is clear that the relationship could last). Individuals with this disorder may feel more secure with transitional objects (i.e., a pet or inanimate possession) than in interpersonal relationships.Differential Diagnoses
Depressive and Bipolar Disorders: Borderline personality disorder often co-occurs with depressive or bipolar disorders, and when criteria for both are met, both should be diagnosed. Because the
cross-sectional presentation of borderline personality disorder can be mimicked by an episode of depressive or bipolar disorder, an additional diagnosis of borderline personality disorder should be avoided based only on cross-sectional presentation without having documented that the pattern of behavior had an early onset and a long-standing course.

Separation Anxiety Disorder: Separation anxiety disorder and borderline personality disorder are characterized by fear of abandonment by loved ones, but problems in identity, self-direction, interpersonal functioning, and impulsivity are additionally central to borderline personality disorder.

Other personality disorders: Other personality disorders may be confused with borderline personality disorder because they have certain features in common. It is therefore important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to borderline personality disorder, all can be diagnosed.
Although histrionic personality disorder can also be characterized by attention seeking, manipulative behavior, and rapidly shifting emotions, borderline personality disorder is distinguished by self-destructiveness, angry disruptions in close relationships, and chronic feelings of deep emptiness and loneliness. Paranoid ideas or illusions may be present in both borderline personality disorder and schizotypal personality disorder, but these symptoms are more transient, interpersonally reactive, and responsive to external structuring in borderline personality disorder. Although paranoid personality disorder and narcissistic personality disorder may also be characterized by an angry reaction to minor stimuli, the relative stability of self-image, as well as the relative lack of physical self-destructiveness, repetitive impulsivity, and profound abandonment concerns, distinguishes these disorders from borderline personality disorder. Although antisocial personality disorder and borderline personality disorder are both characterized by manipulative behavior, individuals with antisocial personality disorder are manipulative to gain profit, power, or some other material gratification, whereas the goal in borderline personality disorder is directed more toward gaining the concern of caretakers. Both dependent personality disorder and borderline personality disorder are characterized by fear of abandonment; however, the individual with borderline personality disorder reacts to abandonment with feelings of emotional emptiness, rage, and demands, whereas the individual with dependent personality disorder reacts with increasing appeasement and submissiveness and urgently seeks a replacement relationship to provide caregiving and support. Borderline personality disorder can further be distinguished from dependent personality disorder by the typical pattern of unstable
and intense relationships.

Identity problems: Borderline personality disorder should be distinguished from an identity problem, which is reserved for identity concerns related to a developmental phase (e.g., adolescence) and does not qualify as a mental disorder. Adolescents and young adults with identity problems (especially when accompanied by substance use) may transiently display behaviors that misleadingly give the impression of borderline personality disorder. Such situations are characterized by emotional instability, existential dilemmas, uncertainty, anxiety-provoking choices, conflicts about sexual orientation, and competing social pressures to decide on careers.Comorbid Disorders
Common co-occurring disorders include depressive and bipolar disorders, substance use disorders, anxiety disorders (particularly panic disorder and social anxiety disorder), eating disorders (notably bulimia nervosa and binge-eating disorder), posttraumatic stress disorder, and ADHD. Borderline personality disorder also frequently co-occurs with the other personality disorders.←

Histrionic Personality Disorder Diagnostic Criteria
A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Is uncomfortable in situations in which they are not the center of attention.
2. Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.
3. Displays rapidly shifting and shallow expression of emotions.
4. Consistently uses physical appearance to draw attention to self.
5. Has a style of speech that is excessively impressionistic and lacking in detail.
6. Shows self-dramatization, theatricality, and exaggerated expression of emotion.
7. Is suggestible (i.e., easily influenced by others or circumstances).
8. Considers relationships to be more intimate than they actually are.Associated Features
Impairment in general tends to be lower in histrionic personality disorder than in many other personality disorders. However, the impairment most associated with histrionic personality disorder appears to be interpersonal in nature. Individuals with histrionic personality disorder have an interpersonal style characterized by social dominance, which can span a spectrum of behaviors that include a “warmer dominance” that can be intrusive in nature (e.g., need to be center of attention; exhibitionistic) to a “colder dominance” that can include arrogant, controlling, and aggressive behaviors. Romantic relationships appear to be particularly impaired, with evidence suggesting that individuals with histrionic personality disorder symptoms are more likely to get divorced or never get married. Individuals with histrionic personality disorder may have difficulty achieving emotional intimacy in romantic or sexual relationships. These individuals may also alienate friends with demands for constant attention. They often become depressed and upset when they are not the center of attention. They may crave novelty, stimulation, and excitement and have a tendency to become bored with their usual routine. These individuals are often intolerant of, or frustrated by, situations that involve delayed gratification, and their actions are often directed at obtaining immediate satisfaction. Although they often initiate a job or project with great enthusiasm, their interest may lag quickly. Longer-term relationships may be neglected to make way for the excitement of new relationships.Differential Diagnoses
Other personality disorders: Other personality disorders may be confused with histrionic personality disorder because they have certain features in common. It is therefore important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to histrionic personality disorder, all can be diagnosed.
Although borderline personality disorder can also be characterized by attention seeking, manipulative behavior, and rapidly shifting emotions, it is distinguished by self-destructiveness, angry disruptions in close relationships, and chronic feelings of deep emptiness and identity disturbance. Individuals with antisocial personality disorder and histrionic personality disorder share a tendency to be impulsive, superficial, excitement seeking, reckless, seductive, and manipulative, but persons with histrionic personality disorder tend to be more exaggerated in their emotions and do not characteristically engage in antisocial behaviors. Individuals with histrionic personality disorder are manipulative to gain nurturance, whereas those with antisocial personality disorder are manipulative to gain profit, power, or some other material gratification. Although individuals with narcissistic personality disorder also crave attention from others, they usually want praise for their “superiority,” whereas individuals with histrionic personality disorder are willing to be viewed as fragile or dependent if this is instrumental in getting attention. Individuals with narcissistic personality disorder may exaggerate the intimacy of their relationships with other people, but they are more apt to emphasize the “VIP” status or wealth of their friends. In dependent personality disorder, the individual is excessively dependent on others for praise and guidance, but is without the flamboyant, exaggerated, emotional features of individuals with histrionic personality disorder.Comorbid Disorders
Histrionic personality disorder has been associated with higher rates of borderline, narcissistic, paranoid, dependent, and antisocial personality disorders; alcohol and other substance use and misuse; as well as aggression and violence. Histrionic personality disorder is also thought to be related to somatic symptom disorder, functional neurological symptom disorder (conversion disorder), and major depressive disorder.←

Narcissistic Personality Disorder Diagnostic Criteria
A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
3. Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
4. Requires excessive admiration.
5. Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations).
6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends).
7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
8. Is often envious of others or believes that others are envious of them.
9. Shows arrogant, haughty behaviors or attitudes.Diagnostic and Associated Features
Individuals with this disorder have a grandiose sense of self-importance, which may be manifest as an exaggerated or unrealistic sense of superiority, value, or capability. They tend to overestimate their abilities and amplify their accomplishments, often appearing boastful and pretentious. They may blithely assume that others attribute the same value to their efforts and may be surprised when the praise they expect and feel they deserve is not forthcoming. Often implicit in the inflated judgments of their own accomplishments is an underestimation or devaluation of the contributions of others. Individuals with narcissistic personality disorder are often preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love. They may ruminate about “long overdue” admiration and privilege and compare themselves favorably with famous or privileged people. Individuals with narcissistic personality disorder believe that they are special or unique and expect others to recognize them as such. They can be surprised or even devastated when the recognition of acclaim they expect and feel they deserve from others is not forthcoming. They may feel that they can only be understood by, and should only associate with, people of high status and may attribute “unique,” “perfect,” or “gifted” qualities to those with whom they associate. Individuals with this disorder believe that their needs are special and beyond the ken of ordinary people. Their own self-esteem is enhanced (i.e., “mirrored”) by the idealized value that they assign to those with whom they associate. They are likely to insist on having only the “top” person (doctor, lawyer, hairdresser, instructor) or being affiliated with the “best” institutions but may devalue the credentials of those who disappoint them.

Individuals with this disorder generally require excessive admiration. Their self-esteem is almost invariably very fragile, and their struggle with severe internal self-doubt, self-criticism, and emptiness results in their need to actively seek others’ admiration. They may be preoccupied with how well they are doing and how favorably they are regarded by others. They may expect their arrival to be greeted with great fanfare and are astonished if others do not covet their possessions. They may constantly fish for compliments, often with great charm.

A sense of entitlement, which is rooted in their distorted sense of self-worth, is evident in these individuals’ unreasonable expectation of especially favorable treatment. They expect to be catered to and are puzzled or furious when this does not happen. For example, they may assume that they do not have to wait in line and that their priorities are so important that others should defer to them, and then get irritated when others fail to assist “in their very important work.” They expect to be given whatever they want or feel they need, no matter what it might mean to others. For example, these individuals may expect great dedication from others and may overwork them without regard for the impact on their lives. This sense of entitlement, combined with a lack of understanding and sensitivity to the wants and needs of others, may result in the conscious or unwitting exploitation of others. They tend to form friendships or romantic relationships only if the other person seems likely to advance their purposes or otherwise enhance their self-esteem. They often usurp special privileges and extra resources that they believe they deserve. Some individuals with narcissistic personality disorder intentionally and purposefully take advantage of others emotionally, socially, intellectually, or financially for their own purposes and gains.

Individuals with narcissistic personality disorder generally have a lack of empathy and are unwilling to recognize or identify with the desires, subjective experiences, and feelings of others. They tend to have some degree of cognitive empathy (understanding another person’s perspective on an intellectual level) but lack emotional empathy (directly feeling the emotions that another person is feeling). These individuals may be oblivious to the hurt their remarks may inflict. When recognized, the needs, desires, or feelings of others are likely to be viewed disparagingly as signs of weakness or vulnerability. Those who relate to individuals with narcissistic personality disorder typically find an emotional coldness and lack of reciprocal interest.

These individuals are often envious of others or believe that others are envious of them. They may begrudge others their successes or possessions, feeling that they better deserve those achievements, admiration, or privileges. They may harshly devalue the contributions of others, particularly when those individuals have received acknowledgment or praise for their accomplishments.

Vulnerability in self-esteem makes individuals with narcissistic personality disorder very sensitive to criticism or defeat. Although they may not show it outwardly, such experiences may leave them feeling ashamed, humiliated, degraded, hollow, and empty. They may react with disdain, rage, or defiant counterattack. However, such experiences can also lead to social withdrawal or an appearance of humility that may mask and protect the grandiosity. Interpersonal relations are typically impaired because of problems related to self-preoccupation, entitlement, need for admiration, and relative disregard for the sensitivities of others.

Low self-esteem with inferiority, vulnerability, and sustained feelings of shame, envy, and humiliation accompanied by self-criticism and insecurity can make individuals with narcissistic personality disorder susceptible to social withdrawal, emptiness, and depressed mood. High perfectionist standards are often associated with significant fear of exposure to imperfection, failure, and overwhelming emotions.Differential Diagnoses
Mania or hypomania: Grandiosity may emerge as part of manic or hypomanic episodes, but the association with mood change or functional impairments helps distinguish these episodes from
narcissistic personality disorder.

Other personality disorders: Other personality disorders may be confused with narcissistic personality disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to narcissistic personality disorder, all can be diagnosed.
The most useful feature in discriminating narcissistic personality disorder from histrionic, antisocial, and borderline personality disorders, in which the interactive styles are coquettish, callous, and needy, respectively, is the grandiosity characteristic of narcissistic personality disorder. The relative stability of self-image and self-control as well as the relative lack of self-destructiveness, impulsivity, separation insecurity, and emotional hyper-reactivity also help distinguish narcissistic personality disorder from borderline personality disorder.
Excessive pride in achievements, a relative lack of emotional display, and ignorance of or disdain for others’ sensitivities help distinguish narcissistic personality disorder from histrionic personality disorder. Although individuals with borderline, histrionic, and narcissistic personality disorders may require much attention, those with narcissistic personality disorder specifically need that attention to be admiring. Individuals with antisocial and narcissistic personality disorders share a tendency to be tough-minded, glib, superficial, exploitative, and unempathetic. However, narcissistic personality disorder does not necessarily include characteristics of impulsive aggressiveness and deceitfulness. In addition, individuals with antisocial personality disorder may be more indifferent and less sensitive to others’ reactions or criticism, and individuals with narcissistic personality disorder usually lack the history of conduct disorder in childhood or criminal behavior in adulthood. In both narcissistic personality disorder and obsessive-compulsive personality disorder, the individual may profess a commitment to perfectionism and believe that others cannot do things as well. However, while those with obsessive-compulsive personality disorder tend to be more immersed in perfectionism related to order and rigidity, individuals with narcissistic personality disorder tend to set high perfectionistic standards, especially for appearance and performance, and to be critically concerned if they are not measuring up.
Suspiciousness and social withdrawal usually distinguish those with schizotypal, avoidant, or paranoid personality disorder from those with narcissistic personality disorder. When these qualities are present in individuals with narcissistic personality disorder, they derive primarily from shame and fear of failure, or fear of having imperfections or flaws revealed.Comorbid Disorders
Narcissistic personality disorder is associated with depressive disorders (persistent depressive disorder and major depressive disorder), anorexia nervosa, and substance use disorders (especially related to cocaine). Histrionic, borderline, antisocial, and paranoid personality disorders may also be associated with narcissistic personality disorder.←

Avoidant Personality Disorder Diagnostic Criteria
A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
1. Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection.
2. Is unwilling to get involved with people unless certain of being liked.
3. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.
4. Is preoccupied with being criticized or rejected in social situations.
5. Is inhibited in new interpersonal situations because of feelings of inadequacy.
6. Views self as socially inept, personally unappealing, or inferior to others.
7. Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.Associated Features
Individuals with avoidant personality disorder often vigilantly appraise the movements and expressions of those with whom they come into contact. They are likely to misinterpret social responses as critical, which in turn confirms their self doubts. They are described by others as being “shy,” “timid,” “lonely,” and “isolated.” The major problems associated with this disorder occur in social and occupational functioning. The low self-esteem and hypersensitivity to rejection are associated with restricted interpersonal contacts. These individuals may become relatively isolated and usually do not have a large social support network that can help them weather crises. They desire affection and acceptance and may fantasize about idealized relationships with others. Avoidant behaviors can also adversely affect occupational functioning because these individuals try to avoid the types of social situations that may be important for meeting the basic demands of the job or for advancement.
:
Individuals with avoidant personality disorder have been reported as having insecure attachment styles characterized by a desire for emotional attachment (which may include a preoccupation with previous and current relationships), but their fears that others may not value them or may hurt them may lead them to respond with passivity, anger, or fear. These attachment patterns have been referred to variously as “preoccupied” or “fearful” depending on the model employed by researchers.Differential Diagnoses
Social Anxiety Disorder: There appears to be a great deal of overlap between avoidant personality disorder and social anxiety disorder. It has been suggested that they may represent different manifestations of similar underlying problems, or avoidant personality disorder may be a more severe form of social anxiety disorder. However, differences have also been described, especially
in relation to self-concept (such as self-esteem and the sense of inferiority in avoidant personality
disorder); the latter is indirect evidence as it shows that negative self-concept in social anxiety
disorder may be unstable and thus less pervasive and entrenched than in avoidant personality disorder.

Agoraphobia: Avoidance characterizes both avoidant personality disorder and agoraphobia, and
they often co-occur. They can be distinguished by the motivation for the avoidance (e.g., fear of
panic or physical harm in agoraphobia).

Other personality disorders: Other personality disorders may be confused with avoidant personality disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to avoidant personality disorder, all can be diagnosed.
Both avoidant personality disorder and dependent personality disorder are characterized by feelings of inadequacy, hypersensitivity to criticism, and a need for reassurance. Similar behaviors (e.g., unassertiveness) and attributes (e.g., low self-esteem and low self-confidence) may be observed in both dependent personality disorder and avoidant personality disorder, although other behaviors are notably divergent, such as avoidance of social proximity in avoidant personality disorder but proximity-seeking in dependent personality disorder. The motivations behind similar behaviors may be quite different. For example, the unassertiveness in avoidant personality disorder is described as more closely related to fears of being rejected or humiliated, whereas in dependent personality disorder it is motivated by the desire to avoid being left to fend for oneself. However, avoidant personality disorder and dependent personality disorder may be particularly likely to co-occur. Like avoidant personality disorder, schizoid personality disorder and schizotypal personality disorder are characterized by social isolation. However, individuals with avoidant personality disorder want to have relationships with others and feel their loneliness deeply, whereas those with schizoid or schizotypal personality disorder may be content with and even prefer their social isolation. Paranoid personality disorder and avoidant personality disorder are both characterized by a reluctance to confide in others. However, in avoidant personality disorder, this reluctance is attributable more to a fear of humiliation or being found inadequate than to a fear of others’ malicious intent.Comorbid Disorders
Other disorders that are commonly diagnosed with avoidant personality disorder include depressive disorders and anxiety disorders, especially social anxiety disorder. Avoidant personality disorder also tends to be diagnosed with schizoid personality disorder. Avoidant personality disorder is associated with increased rates of substance use disorders at a similar rate to the generalized form of social anxiety disorder.←

Dependent Personality Disorder Diagnostic Criteria
A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
1. Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.
2. Needs others to assume responsibility for most major areas of their life.
3. Has difficulty expressing disagreement with others because of fear of loss of support or approval. Do not include realistic fears of retribution.
4. Has difficulty initiating projects or doing things on their own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy).
5. Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant.
6. Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for themself.
7. Urgently seeks another relationship as a source of care and support when a close relationship ends.
8. Is unrealistically preoccupied with fears of being left to take care of themself.Associated Features
The dependent and submissive behaviors are designed to elicit caregiving and arise from a self-perception of being unable to function adequately without the help of others.

Individuals with dependent personality disorder are often characterized by pessimism and self-doubt and tend to belittle their abilities and assets. They take criticism and disapproval as proof of their worthlessness and lose faith in themselves. They may seek overprotection and dominance from others. Occupational functioning may be impaired if independent initiative is required. They may avoid positions of responsibility and become anxious when faced with decisions.Differential Diagnoses
Other personality disorders: Other personality disorders may be confused with dependent personality disorder because they have certain features in common. It is therefore important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to dependent personality disorder, all can be diagnosed.
Although many personality disorders are characterized by dependent features, dependent personality disorder can be distinguished by its predominantly submissive and clinging behavior and by the person’s self-perception of not being able to function adequately without the help and support of others. Both dependent personality disorder and borderline personality disorder are characterized by fear of abandonment; however, the individual with borderline personality disorder reacts to abandonment with feelings of emotional emptiness, rage, and demands, whereas the individual with dependent personality disorder reacts with increasing appeasement and submissiveness and urgently seeks a replacement relationship to provide caregiving and support. Borderline personality disorder can further be distinguished from dependent personality disorder by a typical pattern of unstable and intense relationships. Individuals with histrionic personality disorder, like those with dependent personality disorder, have a strong need for reassurance and approval and may appear childlike and clinging. However, unlike dependent personality disorder, which is characterized by self-effacing and docile behavior, histrionic personality disorder is characterized by gregarious flamboyance with active demands for attention. Moreover, individuals with histrionic personality disorder typically have less insight regarding their underlying dependency needs than do people with dependent personality disorder. Both dependent personality disorder and avoidant personality disorder are characterized by feelings of inadequacy, hypersensitivity to criticism, and a need for reassurance; however, individuals with avoidant personality disorder have such a strong fear of humiliation and rejection that they withdraw until they are certain they will be accepted. In contrast, individuals with dependent personality disorder have a pattern of seeking and maintaining connections to important others, rather than avoiding and withdrawing from relationships.Comorbid Disorders
There may be an increased risk of depressive disorders, anxiety disorders, and adjustment disorders. Dependent personality disorder often co-occurs with other personality disorders, especially borderline, avoidant, and histrionic personality disorders. Chronic physical illness or persistent separation anxiety disorder in childhood or adolescence may predispose the individual to the development of this disorder.←

Obsessive-Compulsive Personality Disorder Diagnostic Criteria
A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
1. Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost.
2. Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met).
3. Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity).
4. Is over-conscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification).
5. Is unable to discard worn-out or worthless objects even when they have no sentimental value.
6. Is reluctant to delegate tasks or to work with others unless others agree to submit to their exact way of doing things.
7. Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes.
8. Shows rigidity and stubbornness.Associated Features
When rules and established procedures do not dictate the correct answer, decision-making may become a time-consuming, often painful process (e.g., exhaustively researching options before making a purchase). Individuals with obsessive-compulsive personality disorder may have such difficulty deciding which tasks take priority or what is the best way of doing some particular task that they may never get started on anything. They are prone to become upset or angry in situations in which they are not able to maintain control of their physical or interpersonal environment, although the anger is typically not expressed directly. For example, an individual may be angry when service in a restaurant is poor, but instead of complaining to the management, the individual ruminates about how much to leave as a tip. On other occasions, anger may be expressed with righteous indignation over a seemingly minor matter. Individuals with this disorder may be especially attentive to their relative status in dominance-submission relationships and may display excessive deference to an authority they respect and excessive resistance to authority they do not respect.

Individuals with this disorder have difficulty relating to and sharing emotions. For example, they may express affection in a highly controlled or stilted fashion and may be very uncomfortable in the presence of others who are emotionally expressive. Their everyday relationships have a formal and serious quality, and they may be stiff in situations in which others would smile and be happy (e.g., greeting a lover at the airport). They carefully hold themselves back until they are sure that whatever they say will be perfect. They may be preoccupied with logic and intellect and intolerant of displays of emotion in others. They often have difficulty expressing tender feelings, rarely paying compliments. Individuals with this disorder may experience occupational difficulties and distress, particularly when confronted with new situations that demand flexibility and compromise.Differential Diagnoses
OCD: Despite the similarity in names, OCD is usually easily distinguished from obsessive-compulsive personality disorder by the presence of true obsessions and compulsions in OCD. When criteria for both obsessive-compulsive personality disorder and OCD are met, both diagnoses can be made.

Hoarding Disorder: A diagnosis of hoarding disorder should be considered especially when hoarding is extreme (e.g., accumulated stacks of worthless objects present a fire hazard and make it difficult for others to walk through the house). When criteria for both obsessive-compulsive personality disorder and hoarding disorder are met, both diagnoses can be made.

Other personality disorders: Other personality disorders may be confused with obsessive-compulsive personality disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to obsessive-compulsive personality disorder, all can be diagnosed.
Individuals with narcissistic personality disorder may also profess a commitment to perfectionism and believe that others cannot do things as well, but these individuals are more likely to believe that they have achieved perfection, whereas those with obsessive-compulsive personality disorder are usually self-critical. Individuals with narcissistic or antisocial personality disorder lack generosity but will indulge themselves, whereas those with obsessive-compulsive personality disorder adopt a miserly spending style toward both self and others. Both schizoid personality disorder and obsessive-compulsive personality disorder may be characterized by an apparent formality and social detachment. In obsessive-compulsive personality disorder, this stems from discomfort with emotions and excessive devotion to work, whereas in schizoid personality disorder there is a fundamental lack of capacity for intimacy.Comorbid Disorders
Individuals with anxiety disorders (e.g., generalized anxiety disorder, separation anxiety disorder, social anxiety disorder, specific phobias) and OCD have an increased likelihood of having a personality disturbance that meets criteria for obsessive-compulsive personality disorder. Even so, it appears that the majority of individuals with OCD do not have a pattern of behavior that meets criteria for this personality disorder. Many of the features of obsessive-compulsive personality disorder overlap with “type A” personality characteristics (e.g., preoccupation with work, competitiveness, time urgency), and these features may be present in individuals at risk for myocardial infarction. There may be an association between obsessive-compulsive personality disorder and depressive and bipolar disorders and eating disorders.←