Personality And Personality Disorders

• Proposed 5 stages of libido development (oral, anal, phallic, latency, genital)
• Personality develops through resolution of conflicts between the id (primitive drives) and social norms (superego) ^[2]
• Failure to resolve these conflicts ("fixation") is said to explain certain personality traits:
  • Oral fixation → dependent, passive traits
  • Anal fixation → obsessional, rigid, controlling traits
  • Phallic fixation → narcissistic, overly competitive traits

• Proposed a lifelong process of personality development with individualization (integration of conscious and unconscious) as the ultimate aim ^[2]

• Proposed 8 developmental stages, each with a specific conflict to be resolved ^[2]:

• Early insecure or anxious attachment with the primary caregiver results in later difficulty in forming relationships ^[2]
• Attachment styles:
  • Secure attachment → healthy interpersonal functioning
  • Anxious-ambivalent attachment → clingy, dependent, fearful of abandonment → dependent PD, borderline PD
  • Anxious-avoidant attachment → emotionally distant, dismissive → schizoid PD, avoidant PD
  • Disorganized attachment (a/w trauma, abuse) → chaotic relationships, dissociation → borderline PD, antisocial PD
• This is one of the most empirically supported models for personality disorder development

• PDs show significant heritability:
  • Antisocial PD: Heritability ~50-70% (one of the highest)
  • Borderline PD: Heritability ~40-65%
  • Histrionic PD: Heritability ~0.67 ^[2]
  • Narcissistic PD: Heritability > 0.6 ^[2]
  • Dependent PD: Heritability 0.55-0.72 ^[2]
  • Obsessive-compulsive PD: Associated with DRD3 gene ^[2]
  • Schizotypal PD: Shares genetic risk with schizophrenia-spectrum disorders ^[7]
• Paranoid PD: Has a genetic relationship with delusional disorder ^[2]
• Schizotypal PD: Shares genetic risk with schizophrenia, schizoaffective disorder, and paranoid PD ^[7] — it is essentially on the "schizophrenia spectrum"

• Antisocial PD:
  • Reduced prefrontal cortex volume (especially orbitofrontal) → impaired impulse control and moral reasoning
  • Reduced amygdala reactivity → diminished fear conditioning and empathy
  • Low autonomic arousal → reduced anticipatory anxiety → failure to learn from punishment
• Borderline PD:
  • Amygdala hyperreactivity → exaggerated emotional responses
  • Prefrontal cortex hypoactivity → poor emotional regulation
  • Reduced hippocampal volume (likely related to early trauma/chronic stress)
  • Altered serotonergic function → impulsivity and aggression
• Histrionic PD: Hypothesized to involve highly responsive noradrenergic systems ^[2]
• Narcissistic PD: Structural differences in neural circuitry for empathy ^[2]
• Cluster A PDs: Show some of the same neurobiological abnormalities as schizophrenia (e.g., dopaminergic dysregulation, cognitive processing deficits)

• Serotonin: Low serotonergic function consistently associated with impulsivity and aggression (relevant to Cluster B, especially borderline and antisocial)
• Dopamine: Implicated in reward-seeking and novelty-seeking behaviour (relevant to antisocial and narcissistic PDs), and in the schizophrenia-spectrum disorders (Cluster A)
• Noradrenaline: May contribute to emotional reactivity (histrionic PD)
• Oxytocin/vasopressin: Emerging evidence for roles in attachment and trust (relevant to all PDs with interpersonal dysfunction)

This is arguably the most important aetiological domain, especially for Cluster B:

• Borderline PD: Strong association with:
  • Childhood physical and sexual abuse (reported in 40-70% of cases)
  • Emotional neglect and invalidating environments (Linehan's biosocial theory: the child's emotional experiences are persistently invalidated → they never learn to regulate emotions)
  • Disorganized attachment patterns
• Antisocial PD: Associated with:
  • Childhood conduct disorder (required for diagnosis)
  • Parental criminality, substance abuse
  • Harsh, inconsistent, or absent parenting
  • Early institutionalization
• Avoidant PD: Associated with childhood emotional neglect and peer group rejection ^[2]
• Dependent PD: Associated with overprotective and authoritarian parenting and early traumatic experiences ^[2]
• Narcissistic PD: Associated with parental overprotectiveness and overvaluation coupled with frustration and rejection ^[2]
• OCPD: Associated with overprotective or over-involved parenting and triggered by trauma ^[2]

• Histrionic PD: Freud proposed failure of mature intimacy + unresolved Oedipus complex → oversexualization of relationships ^[2]
• Borderline PD: Object relations theory (Kernberg) — failure to integrate "good" and "bad" representations of self and others → splitting as a defence mechanism
• Antisocial PD: Failure of superego development → absence of guilt and moral conscience

This is a cross-cutting theme across psychiatry:

• Neuroticism → depression, anxiety disorders ^[3][4]
• Behavioural inhibition → avoidant PD, social anxiety disorder, GAD ^[6]
• Sensation-seeking, impulsivity → substance use disorders, antisocial PD ^[5]
• Sociotropy (strong need for peer approval) → depression ^[3]

Clinical Features (with pathophysiology):

• Suspects, without sufficient basis, that others are exploiting, harming, or deceiving them → This stems from a cognitive schema of "the world is dangerous and others cannot be trusted," likely rooted in early experiences of betrayal or insecure attachment
• Preoccupied with unjustified doubts about loyalty/trustworthiness of friends/associates → Hypervigilance and threat detection bias (similar to the amygdala hyperreactivity seen in anxiety but here projected onto social relationships)
• Reluctant to confide in others because of fear that information will be used against them
• Reads hidden demeaning or threatening meanings into benign remarks → Cognitive bias toward hostile attribution
• Persistently bears grudges (unforgiving of insults, injuries, slights)
• Perceives attacks on character not apparent to others and is quick to react angrily or counterattack
• Recurrent suspicions regarding fidelity of spouse/partner without justification
• Emotionally cold, distant, humourless, with limited capacity for warm interpersonal engagement

Why does this matter clinically?

• These patients are extremely difficult to engage in treatment because they don't trust the therapist
• They may present with comorbid anxiety or depression but the underlying paranoid traits make treatment challenging
• Important to differentiate from delusional disorder (paranoid type) — in PD, beliefs are overvalued ideas (not fixed delusions), and reality testing is partially preserved

Clinical Features (with pathophysiology):

• Neither desires nor enjoys close relationships, including being part of a family → Not due to anxiety (cf. avoidant PD) but a fundamental lack of interest in social bonds — think of it as an absence of the social drive
• Almost always chooses solitary activities → Preference, not avoidance
• Little, if any, interest in sexual experiences with another person
• Takes pleasure in few, if any, activities → Restricted hedonic capacity (anhedonia-like but stable, not episodic)
• Lacks close friends or confidants other than first-degree relatives
• Appears indifferent to praise or criticism → Emotional flatness is genuine, not defensive
• Shows emotional coldness, detachment, or flattened affectivity
• Rich inner fantasy life may be present (distinguishing feature)

Clinical Features (with pathophysiology):

• Ideas of reference (not delusions of reference) → Cognitive processing bias, subthreshold psychotic-like experience
• Odd beliefs or magical thinking inconsistent with cultural norms (e.g., telepathy, clairvoyance, "sixth sense")
• Unusual perceptual experiences including bodily illusions
• Odd thinking and speech (vague, circumstantial, metaphorical, overelaborate)
• Suspiciousness or paranoid ideation → Overlaps with paranoid PD
• Inappropriate or constricted affect
• Odd, eccentric, or peculiar behaviour or appearance
• Lacks close friends other than first-degree relatives
• Excessive social anxiety that does not diminish with familiarity (and is associated with paranoid fears rather than negative self-judgments)

Pathophysiology: Schizotypal PD is best understood as a milder, attenuated form of schizophrenia — same genetic vulnerability, similar (but less severe) neurobiological abnormalities (dopamine dysregulation, structural brain changes), but without the frank psychosis. About 10-25% of individuals with schizotypal PD will eventually develop schizophrenia.

Clinical Features (with pathophysiology):

• Pervasive pattern of disregard for and violation of the rights of others since age 15
• Failure to conform to social norms → Deficient superego development (psychoanalytic view); impaired prefrontal cortical function (neurobiological view) → poor moral reasoning and consequence evaluation
• Deceitfulness: Repeated lying, use of aliases, conning others for personal profit/pleasure → Interpersonal manipulation reflecting callous-unemotional traits
• Impulsivity or failure to plan ahead → Prefrontal hypofunction → poor executive function and delay discounting (preference for immediate reward over delayed larger reward)
• Irritability and aggressiveness: Repeated physical fights or assaults → Low serotonergic tone → reduced threshold for aggressive response; amygdala hypoactivation → reduced fear response
• Reckless disregard for safety of self or others → Low autonomic arousal → sensation-seeking to achieve "normal" arousal levels
• Consistent irresponsibility: Failure to sustain consistent work behaviour or honour financial obligations
• Lack of remorse: Indifference to or rationalizing having hurt, mistreated, or stolen from another → Deficient empathic processing; structural differences in anterior insula and anterior cingulate cortex

The "psychopath" concept: Note that ASPD and psychopathy are not the same thing. ASPD is a diagnosis focused on behavioural criteria (criminal/irresponsible behaviour). Psychopathy (assessed by Hare's Psychopathy Checklist-Revised, PCL-R) emphasizes interpersonal and affective deficits (superficial charm, grandiosity, callousness, lack of remorse). Most psychopaths meet ASPD criteria, but most people with ASPD are not psychopaths.

This is arguably the most clinically important personality disorder and the one with the most evidence for effective treatment.

Clinical Features (with pathophysiology):

• Frantic efforts to avoid real or imagined abandonment → Rooted in insecure (disorganized) attachment; amygdala hyperreactivity to perceived social rejection → intense fear response even to ambiguous social cues
• Unstable and intense interpersonal relationships, alternating between extremes of idealization and devaluation ("splitting") → Object relations failure — inability to hold simultaneously positive and negative views of the same person → black-and-white thinking. When the person meets their needs, they are "perfect"; when they don't, they are "terrible"
• Identity disturbance: Markedly and persistently unstable self-image or sense of self → Corresponds to Erikson's stage 5 failure (identity vs. role confusion); neurobiologically, anterior cingulate and medial prefrontal dysfunction impairs self-referential processing
• Impulsivity in ≥2 areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating) → Prefrontal cortex hypofunction → poor impulse control; dopaminergic reward system dysregulation → seeking stimulation
• Recurrent suicidal behaviour, gestures, threats, or self-mutilating behaviour → Self-harm often serves an emotional regulation function ("I feel so much emotional pain that physical pain provides relief" or "I feel so numb that pain makes me feel alive"); also serves an interpersonal function (communicating distress)
• Affective instability due to marked reactivity of mood → Amygdala hyperreactivity + prefrontal hypoactivity → inability to modulate emotional responses → rapid mood shifts lasting hours (not days as in bipolar)
• Chronic feelings of emptiness → Related to identity disturbance and lack of stable internal object representations
• Inappropriate, intense anger or difficulty controlling anger → Serotonergic dysfunction + amygdala hyperreactivity
• Transient, stress-related paranoid ideation or severe dissociative symptoms → Under extreme stress, the cognitive processing becomes so overwhelmed that brief psychotic-like symptoms emerge (this is NOT schizophrenia — symptoms are transient and stress-related)

Linehan's Biosocial Model (the most influential model for BPD):

1. Biological vulnerability: Innate emotional vulnerability (high sensitivity, high reactivity, slow return to baseline) — likely genetically determined temperament
2. Invalidating environment: Childhood environment that persistently dismisses, punishes, or ignores the child's emotional experiences ("stop crying," "you're overreacting," "that's nothing to be upset about")
3. Result: The child never learns to label, understand, or regulate their emotions → emotional dysregulation becomes the core pathology → all other BPD features flow from this

Clinical Features (with pathophysiology):

• Self-dramatization with emotional blackmail, angry scenes, demonstrative suicide attempts ^[2] → The dramatic displays serve as interpersonal strategies to maintain attention and control; rooted in a core belief that "I am inadequate unless I can capture others' attention"
• Often suggestible, especially by figures of authority ^[2] → Reflects poor self-structure and identity dependence on external validation
• Seek attention and excitement, easily bored, have short-lived enthusiasm and shallow, labile affect ^[2] → The shallow affect reflects that emotional displays are performative rather than deeply felt; the boredom reflects understimulated noradrenergic/reward systems
• Self-centred with marked capacity for self-deception to convince themselves of their own fabrications ^[2]
• Over-concerned with physical attractiveness ^[2] → Physical appearance is the primary tool for gaining attention
• Seek intimacy and inappropriately seductive ^[2] → Sexualization of relationships as the primary means of relating to others (per Freud's model)

Clinical Features (with pathophysiology):

• Grandiose sense of self-importance, considers self as deserving of special treatment — rigid, inflexible but easily threatened (very dependent on feedback) ^[2] → The grandiosity is a defensive structure protecting a fragile, insecure inner self. When the narcissistic "supply" (admiration, attention) is cut off, the person decompensates
• Boastful and pretentious with excessive need for admiration (e.g., need to be the centre of attention) ^[2]
• Superficial and exploitative relationships, with only value being self-enhancement (e.g., associating with rich, famous people) ^[2]
• Lack of empathy: even if attuned to others' reactions, only does so to serve own needs ^[2] → Neural circuitry for empathy is structurally different → cognitive empathy may be intact (can read emotions) but affective empathy is deficient (doesn't feel what others feel)
• Chronic emptiness and boredom when without positive feedback, but feel vulnerable during life transitions ^[2]
• Subtypes ^[2]:
  • High-functioning: Successful, charismatic, but interpersonally exploitative
  • Grandiose/overt ("thick-skinned"): Classic presentation — boastful, entitled, dismissive
  • Vulnerable/covert ("thin-skinned"): Shy, hypersensitive to criticism, easily hurt, chronic feelings of emptiness
• Associated with significant risk of suicide and substance use ^[2]

Clinical Features (with pathophysiology):

• Avoids interpersonal contact for fears of criticism, disapproval, rejection unless certain of being liked ^[2] → Core cognitive schema: "I am fundamentally inadequate and will be rejected if others see the real me"
• Preoccupied with criticism/rejection in social situations ^[2] → Attention bias toward threat cues (similar to social anxiety disorder)
• Persistently tense, insecure, and lacks self-esteem ^[2]
• Feels socially inferior, inept, unappealing ^[2]
• Has few close friends but craves social relationships ^[2] → This is the key difference from schizoid PD (who doesn't want relationships)

Avoidant PD vs. Social Anxiety Disorder (SAD): There is enormous overlap. Some experts consider avoidant PD to be the more severe, generalized end of the social anxiety spectrum. The main distinction is that avoidant PD involves pervasive feelings of inadequacy and inferiority across all life domains, while SAD is more specifically related to fear of social performance situations. In practice, many patients meet criteria for both.

Clinical Features (with pathophysiology):

• Pervasive and excessive need to be taken care of, sometimes going to excessive lengths to obtain such care ^[2] → Core schema: "I am helpless and cannot survive on my own." This likely develops from overprotective parenting that never allowed autonomy (Erikson stage 2 failure: autonomy vs. shame)
• Unduly compliant with difficulty making direct demands or disagreeing with other people ^[2] → Fear that assertiveness will lead to abandonment
• Lacks confidence and therefore avoids responsibility ^[2]
• Often protected by a more energetic partner ^[2] → Classic dynamic: the dependent person pairs with a controlling or narcissistic partner
• Often preoccupied with fears of being left alone and urgently seeks another relationship when an earlier one ended ^[2] → "Relationship hopping" — the person cannot tolerate being alone

Clinical Features (with pathophysiology):

• Preoccupied with orderliness, perfectionism, and control at the expense of flexibility, openness, and efficiency → Core schema: "The world is unpredictable and dangerous; I must maintain control at all times to prevent catastrophe"
• Excessive devotion to work and productivity to the exclusion of leisure and friendships
• Over-conscientiousness, scrupulosity, inflexibility about matters of morality, ethics, or values
• Inability to discard worn-out or worthless objects (hoarding — but this is different from Hoarding Disorder)
• Reluctance to delegate tasks unless they submit to exactly their way of doing things
• Miserliness (money viewed as something to be hoarded for future catastrophes)
• Rigidity and stubbornness
• Preoccupation with details, rules, lists, order to the extent that the major point of activity is lost

This is the single most important differential in personality disorder diagnosis, and it appears repeatedly in lectures and exams ^[13][14].

Bipolar spectrum: bothered by frequent mood changes, can be mistaken as borderline personality disorder ^[14]

In mania, these S/S usually change quickly in content and seldom outlast mood disruption. In psychotic disorders, psychosis occurs outside of mood disturbances ^[2]

Borderline personality disorder: Often a/w marked affective instability → mimics rapid cycling bipolar disorder. Discerning features: No FHx of BAD; Rapid shifts of mood (e.g. over hours and days); No classic symptoms of mania, e.g. ↑energy, grandiosity; Mood disturbances often triggered by interpersonal issues ^[2]

• Chronic/undertreated depression can look like avoidant PD (social withdrawal), dependent PD (helplessness), or even borderline PD (irritability, emptiness)
• Dysthymia (persistent depressive disorder): Persistent low mood for ≥2 years may be confused with a "depressive personality." The key is that dysthymia has an identifiable onset and represents a change from premorbid baseline, whereas PD traits were present before mood symptoms ^[2][15]
• Neuroticism overlaps heavily with both depression and Cluster C PDs ^[2][15]
• Key differentiator: In depression, the symptoms remit (at least partially) with treatment. Personality traits persist even when mood improves

Personality disorder with prominent irritability is listed as a differential of manic episode in lecture slides ^[13]:

• Differential diagnosis of manic episode: Personality disorder with prominent irritability ^[13]
• Discerning features: personality-driven irritability is constant and trait-like; manic irritability is episodic, with associated features (↑energy, ↓need for sleep, grandiosity, pressured speech)

• Schizotypal (personality) disorder: a personality disorder (trait-like, > 2y) characterized by eccentric behaviour, anomalies of thinking and affect that resembles schizophrenia but without overt schizophrenia ^[2]
• Chronic with fluctuating course, may evolve into overt schizophrenia ^[2]
• Considered part of schizophrenic spectrum ^[2]
• Key differences: Schizotypal PD has subthreshold psychotic-like experiences (ideas of reference, not delusions; unusual perceptual experiences, not hallucinations). Schizophrenia has frank psychosis meeting Criterion A (delusions, hallucinations, disorganized speech/behaviour, negative symptoms) for ≥1 month

• Paranoid PD involves overvalued ideas (suspicion, mistrust) — beliefs that are strongly held but not of delusional intensity; reality testing is partially preserved
• Delusional disorder involves fixed, unshakeable delusions (e.g., persecutory) for ≥1 month (DSM-5) / ≥3 months (ICD-10), with relatively preserved functioning apart from the delusion
• Paranoid PD has a genetic relationship with delusional disorder ^[2] — they may be on the same spectrum

• BPD can feature transient, stress-related paranoid ideation or severe dissociative symptoms — these are brief (hours to days), triggered by interpersonal stress, and resolve when the stressor is removed
• In schizophrenia and related psychotic disorders, psychosis is sustained, often independent of identifiable stressors, and requires antipsychotic treatment

• There is massive overlap — many experts consider avoidant PD to be the severe end of the social anxiety spectrum
• Both involve fear of negative evaluation and social avoidance
• DDx for avoidance features: Personality disorder, psychosis, depression ^[16]
• Key differences:
  • Avoidant PD: Pervasive feelings of inadequacy/inferiority across all life domains (not just social performance); identity is built around being "defective"
  • SAD: Fear is more specifically related to social performance situations (public speaking, eating in public)
  • In practice, most patients with avoidant PD also meet criteria for SAD

• OCPD: Ego-syntonic perfectionism without intrusive thoughts or compulsions
• OCD: Ego-dystonic intrusive thoughts with compulsive rituals. Recurrent thoughts/ruminations and avoidant behaviours may also be present. However, content tends to be related to real-life concerns in GAD compared to odd, irrational or magical beliefs in OCD ^[2]
• GAD: Pervasive worry about real-life concerns (health, finances, family) — not the focused, irrational obsessions of OCD or the rigid perfectionism of OCPD

This is a useful clinical framework from the senior notes ^[2]:

• Separation or abandonment → borderline, dependent personality disorder ^[2]
• Being rejected or inadequate → avoidant personality disorder ^[2]
• Worry about gaining weight → eating disorder
• Worry about serious illness → hypochondriacal disorder
• Fear of being poisoned/killed → paranoid schizophrenia
• Ruminatory guilt/worthlessness → depression
• Associated with obsessional thoughts → OCD

This is an increasingly recognized and clinically important distinction (especially since ICD-11 introduced Complex PTSD as a formal diagnosis):

• Some personality features may be associated with vulnerability to situational distress that may resemble an adjustment disorder. It is important to understand the lifetime history of personality functioning ^[2]

• Personality disorder: Some personality features may be a/w vulnerability to situational distress that may resemble an adjustment disorder ^[2]
• Key: In adjustment disorder, the distress is time-limited (develops within 3 months of stressor, resolves within 6 months of stressor ending). In PD, the maladaptive patterns were present before the stressor and will persist after it resolves

Personality or neurodevelopmental disorders, e.g. ADHD, borderline personality disorder: May have features similar to hypomania, e.g. impulsivity, temper, mood lability. Tends to involve more stable and enduring behaviour pattern (cf episodic in mania) ^[2]

ADHD and mania are both a/w distractibility, impulsivity and talkativeness. In BAD, these features tend to occur episodically and may be a/w elated mood and grandiosity ^[2] ADHD should not have ↑self-esteem, grandiosity, flight of ideas, ↓need of sleep ^[2]

A pervasive distrust and suspiciousness of others, beginning by early adulthood, present in a variety of contexts, as indicated by ≥4 of:

1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving them
2. Preoccupied with unjustified doubts about loyalty or trustworthiness of friends/associates
3. Reluctant to confide due to unwarranted fear information will be used maliciously
4. Reads hidden demeaning or threatening meanings into benign remarks or events
5. Persistently bears grudges (unforgiving of insults, injuries, slights)
6. Perceives attacks on character or reputation not apparent to others and is quick to react angrily
7. Recurrent suspicions, without justification, regarding fidelity of spouse or partner

Does not occur exclusively during schizophrenia, bipolar/depressive disorder with psychotic features, or another psychotic disorder, and is not due to a medical condition.

A pervasive pattern of detachment from social relationships and restricted emotional expression, beginning by early adulthood, as indicated by ≥4 of:

1. Neither desires nor enjoys close relationships, including family
2. Almost always chooses solitary activities
3. Has little, if any, interest in 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 praise or criticism
7. Shows emotional coldness, detachment, or flattened affectivity

A pervasive pattern of social and interpersonal deficits marked by acute discomfort with close relationships, cognitive/perceptual distortions, and eccentricities of behaviour, beginning by early adulthood, as indicated by ≥5 of:

1. Ideas of reference (excluding delusions of reference)
2. Odd beliefs or magical thinking inconsistent with subcultural norms
3. Unusual perceptual experiences, including bodily illusions
4. Odd thinking and speech (vague, circumstantial, metaphorical, overelaborate, stereotyped)
5. Suspiciousness or paranoid ideation
6. Inappropriate or constricted affect
7. Behaviour 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 is associated with paranoid fears rather than negative self-judgments

Does not occur exclusively during schizophrenia, bipolar/depressive disorder with psychotic features, another psychotic disorder, or ASD.

A pervasive pattern of disregard for and violation of the rights of others, since age 15, as indicated by ≥3 of:

1. Failure to conform to social norms with respect to lawful behaviours (repeatedly performing acts that are grounds for arrest)
2. Deceitfulness (repeated lying, use of aliases, conning others for personal profit/pleasure)
3. Impulsivity or failure to plan ahead
4. Irritability and aggressiveness (repeated physical fights or assaults)
5. Reckless disregard for safety of self or others
6. Consistent irresponsibility (repeated failure to sustain consistent work behaviour or honour financial obligations)
7. Lack of remorse (indifferent to or rationalizing having hurt/mistreated/stolen from another)

Additional requirements:

• Individual is at least age 18 years
• There is evidence of conduct disorder with onset before age 15
• Not exclusively during course of schizophrenia or bipolar disorder

Why the age and conduct disorder requirements? Because ASPD is conceptualized as the adult continuation of childhood-onset behavioural pathology. Without the conduct disorder criterion, you'd be diagnosing personality traits that didn't emerge until adulthood — more likely to be situational, substance-related, or secondary to another disorder.

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood, as indicated by ≥5 of:

1. Frantic efforts to avoid real or imagined abandonment
2. Unstable and intense interpersonal relationships, alternating between extremes of idealization and devaluation ("splitting")
3. Identity disturbance: markedly and persistently unstable self-image or sense of self
4. Impulsivity in ≥2 areas that are potentially self-damaging (spending, sex, substance abuse, reckless driving, binge eating)
5. Recurrent suicidal behaviour, gestures, threats, or self-mutilating behaviour
6. Affective instability due to a marked reactivity of mood (intense episodic dysphoria, irritability, or anxiety usually lasting hours, rarely days)
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger
9. Transient, stress-related paranoid ideation or severe dissociative symptoms

5 out of 9 criteria are needed. The most commonly endorsed features in clinical practice are affective instability (#6), impulsivity (#4), and unstable relationships (#2).

A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood, as indicated by ≥5 of:

1. Uncomfortable when not the centre of attention
2. Interaction with others often characterized by inappropriately sexually seductive or provocative behaviour
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 (easily influenced by others or circumstances)
8. Considers relationships to be more intimate than they actually are

A pervasive pattern of grandiosity (in fantasy or behaviour), need for admiration, and lack of empathy, beginning by early adulthood, as indicated by ≥5 of:

1. Grandiose sense of self-importance (exaggerates achievements/talents, expects to be recognized as superior without commensurate achievements)
2. Preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
3. Believes they are "special" and unique and can only be understood by, or should associate with, other special or high-status people/institutions
4. Requires excessive admiration
5. Has a sense of entitlement (unreasonable expectation of favourable treatment or automatic compliance)
6. Is interpersonally exploitative (takes advantage of others to achieve own ends)
7. Lacks empathy: unwilling to recognize or identify with the feelings/needs of others
8. Is often envious of others or believes others are envious of them
9. Shows arrogant, haughty behaviours or attitudes

A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood, as indicated by ≥4 of:

1. Avoids occupational activities involving significant interpersonal contact because of fears of criticism, disapproval, or rejection
2. Unwilling to get involved with people unless certain of being liked
3. Shows restraint within intimate relationships because of fear of being shamed or ridiculed
4. Preoccupied with being criticized or rejected in social situations
5. Inhibited in new interpersonal situations because of feelings of inadequacy
6. Views self as socially inept, personally unappealing, or inferior to others
7. Unusually reluctant to take personal risks or engage in any new activities because they may prove embarrassing

A pervasive and excessive need to be taken care of that leads to submissive and clinging behaviour and fears of separation, beginning by early adulthood, as indicated by ≥5 of:

1. Difficulty making everyday decisions without excessive advice/reassurance from others
2. Needs others to assume responsibility for most major areas of life
3. Difficulty expressing disagreement with others because of fear of loss of support or approval
4. Difficulty initiating projects or doing things on own (because of lack of self-confidence in judgment/abilities)
5. Goes to excessive lengths to obtain nurturance and support (even to point of volunteering for unpleasant tasks)
6. Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for self
7. Urgently seeks another relationship as a source of care and support when a close relationship ends
8. Unrealistically preoccupied with fears of being left to take care of self

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, as indicated by ≥4 of:

1. 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
3. Excessively devoted to work and productivity to the exclusion of leisure and friendships (not accounted for by economic necessity)
4. Over-conscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification)
5. Unable to discard worn-out or worthless objects even when they have no sentimental value
6. Reluctant to delegate tasks or work with others unless they submit to exactly their way of doing things
7. Adopts a miserly spending style toward both self and others (money viewed as something to be hoarded for future catastrophes)
8. Shows rigidity and stubbornness