F6 Disorder of

Adult Personality
and Behaviour
 F60 Specific personality disorder

F61 Mixed and other personality disorder

F62 Enduring personality changes, not

attributable to brain damage and disease

F63 Habit and impulse disorder

Classification - ICD 10
F64 Gender identity disorder

F65 Disorders of sexual preference

F66 Psychological and behavioral disorders

associated with sexual development and
orientation

F68 Other disorders of adult personality

and behavior

F69 Unspecified disorder of adult

personality and behavior
 ● Personality Disorders
(F60-F62)
Classification - DSM V ● Disruptive, Impulse-Control,
and Conduct Disorders (F63)
● Gender Dysphoria (F64)
● Paraphilic Disorders (F65)
Personality Disorder
Definition and Epidemiology
Personality → all the characteristic that adapt in unique ways to ever-changing
internal and external environments

10-20% of the general population, 50% of all psychiatric patients (frequently

comorbid with other clinical syndrome)
Etiology
● Genetic factors
○ Cluster A → more common, especially schizotypal with schizophrenia
○ Cluster B → borderline personality disorder with mood disorders, histrionic with
somatization disorder
● Biological factors
○ Hormones → androgen increase aggression and sexual behavior
○ Platelet monoamine oxidase (MAO) → low platelet MAO associated with sociability
○ Neurotransmitters → endorphins in phlegmatic persons; low 5-HIAA (serotonin
metabolite) in person who attempt suicide, impulsive and aggressive patient; increase
dopamine cause euphoria
○ Electrophysiology → antisocial and borderline types has slow-wave activity on EEG
● Psychoanalytic factors
○ Freud → fixation at psychosexual stage of development
■ Oral stage → passive and dependent
■ Anal stage → stubborn, parsimonious, highly conscientious
○ Defense mechanism → unconscious mental processes that the ego uses to resolve
conflicts among the four lodestars of inner life: instinct (wish or need), reality, important
persons, conscience
■ Fantasy → schizoid → making imaginary lives, seek solace and satisfaction within
themselves, unsociableness rests on fear of intimacy
■ Dissociation/denial → replacement of unpleasant affect with pleasant ones,
dramatizing and emotionally shallow → histrionic
■ Projection → paranoid → excessive faultfinding and sensitivity to criticism
■ Projective identification → borderline personality
Diagnosis Criteria - DSM V
A. An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the
individual’s culture. This pattern is manifested in two (or more ) of the following areas:
1. Cognition
2. Affectively
3. Interpersonal functioning
4. Impulse control
B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situation
C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other
important areas of functioning
D. The pattern is stable and of long duration, and first onset can be traced back at least to adolescence or early
adulthood
E. The enduring pattern is not better explained as a manifestation or consequence of another mental disorder
F. The enduring pattern is not attibutable to the physiological effects of a substance or another medical condition
Diagnosis Criteria - ICD 10
1. Markedly dysharmonious attitudes and behaviour, involving usually several areas of
functioning, eg affectivity, arousal impulse control, ways of perceiving and thinking, and style of
relating to others
2. THe abnormal behaviour pattern is enduring, of long standing, and not limited to episodes of
mental illness
3. The abnormal behaviour pattern is pervasive and clearly 6to a broad range of personal and
social situations
4. The above manifestations always appear during childhood or adolescence and continue into
adulthood
5. The disorder leads to considerable personal distress but this may only becoma apparent late in
its course
6. The disorder is usually, but not invariably, associated with significant problem in occupational
and social performance
Classification
DSM V ICD 10

● Cluster A ● F60.0 Paranoid personality disorder

○ Paranoid ● F60.1 Schizoid personality disorder
○ Schizoid ● F60.2 Dissocial personality disorder
○ Schizotypal ● F60.3 Emotionally unstable personality
● Cluster B disorder
○ .30 Impulsive type
○ Antisocial
○ .31 Borderline
○ Borderline
○ Histrionic ● F60.4 Histrionic personality disorder
● F60.5 Anankastic personality disorder
○ Narcissistic
● F60.6 Anxious [avoidant] personality disorder
● Cluster C
● F60.7 Dependent personality disorder
○ Anancastic
● F60.8 Other personality disorder
○ Dependent
● F60.9 Personality disorder, unspecified
○ Avoidant
Paranoid
Definition and Epidemiology
Characteristic: long-standing suspiciousness and mistrust of persons in
general; often hostile, irritable, and angry

Tendency to interpret action of others as deliberately demeaning, malevolent,

threatening, exploiting, or deceiving. Ideas of reference and logically defended
illusions are common

They lack warmth and are impressed with power and rank; express disdain for
those they see as weak, sickly, impaired, defective

Defense mechanism: projection → attribute to others the impulses and

thoughts that they cannot accept in themselves

2-4% of general population

Diagnosis Criteria - DSM V
A. A pervasive distrust and suspiciousness of others such that theri motives are interpreted as
mavevolent, beginning by early adulthood and present in a variety of context, as indicated by 4
or more of the following
1. Suspect, without sufficient basis, that others are exploiting harming, or deceiving him/her
2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or
associates
3. Is reluctant to confide with other because of unwarranted fear for that the information
will be used maliciously against him or her
4. Read hidden demeaning or threatening meanings into benign remarks or events
5. Persistently bear grudges
6. Perceives attack 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 other mental disorder, substance use or medical condition
Diagnosis Criteria - ICD 10
1. Excessive sensitiveness to setbacks and rebuffs
2. Tendency to bear grudges persistently (refusal to forgive insults and injuries or
slights)
3. Suspiciousness and a pervasive tendency to distort experience by misconstruing
the neutral or friendly actions of others as hostile or contemptuous
4. A combative and tenacious sense of personal rights out of keeping with the actual
situation
5. Recurrent suspicions, without justification, regarding sexual fidelity of spouse or
sexual partner
6. Tendency to experience excessive self-importance, manifest in a persistent
self-referential attitude
7. Preoccupation with unsubstantiated “conspiratorial” explanations of events both
immediate to the patient and in the world at large
Therapy
● Psychotherapy → therapy of choice
○ Therapist should be straightforward in all their dealings, appear professional and not
overly warm → trust and toleration of intimacy are troubled areas for patient
○ Overzealous use of interpretation increase patients’ mistrust
○ Sometimes need to set limits on their action
● Pharmacotherapy
○ Agitation and anxiety
■ Anxiolytic → diazepam
■ Antipsychotic → haloperidol
Schizoid
Definition and Epidemiology
Characteristic: lifelong pattern of social withdrawal

Often seen as eccentric, isolated, lonely, cold, aloof, display remote reserve

Discomfort with human interaction; appear quiet, distant, seclusive,

unsociable; can invest energy in nonhuman interest such as math and
astronomy

Defense mechanism: fantasy → fantasized omnipotence or resignation

5% of population, gravitate toward solitary jobs that involve little or no contact

with others
Diagnosis Criteria - DSM V
A. A pervasive pattern of detachment from social relationships and a restricted range of
expression of emotions is beginning by early adulthood and present in a variety of context, as
indicated by 4 or more of the following
1. Neither desire nor enjoys close relationships, including being part of a family
2. Almost always chooses solitary activiites
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 other
7. Show emotional coldness, detachment, or flattened affectivity
B. Does not occur exclusively during the course of other mental disorder, substance use or medical condition
Diagnosis Criteria - ICD 10
1. Few, if any, activities, provide pleasure
2. Emotional coldness, detachment or flattened affectivity
3. Limited capacity to express either warm, tender feelings or anger towards
others
4. Apparent indifference to either praise or criticism
5. Little interest in having sexual experiences with another person (taking
into account age)
6. Almost invariable preference for solitary activities
7. Excessive preoccupation with fantasy and introspection
8. Lack of close friends or confiding relationships (or having only one) and of
desire for such relationship
9. Marked insensitivity to prevailing social norms and conventions
Therapy
● Psychotherapy
○ Patient tend toward introspection, but consistent with psychotherapists expectation
○ If trust develops → may reveal plethora of fantasies, imaginary friends, and fears of
unbearable dependence
○ Group therapy → should be protected against aggressive attack by group members for
their proclivity to be silent
● Pharmacotherapy
○ Small dosage of antipsychotics, antidepressant, and psychostimulants
○ Benzodiazepine may help diminish interpersonal anxiety
Schizotypal
Definition, Epidemiology, Etiology
Strikingly odd or strange, even to laypersons; magical thinking, peculiar
notions, ideas of reference, illusions, and derealization

Disturbed thinking and communicating; may not know their own feelings and
yet ar exquisitely sensitive to the feelings of others especially negative affects

Inner world may be filled with vivid imaginary relationship and child-like fears
and fantasies

3% of population, frequently diagnosed in fragile X syndrome

Etiology: adoption, family, and twin studies demonstrate increased prevalence

of schizotypal features in the families of schizophrenic patients
Diagnosis Criteria - DSM V
A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and
reduced capacity for, close relationship as well as by cognitive or perceptual distortions, and
eccentricities of behavior, beginning by early adulthood and present in a variety of context, as
indicated by 5 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 à
clairvoyance, telepathy, sixth sense
3. Unusual perceptual experiences, including bodily illusions
4. Odd thinking and speech à circumstantial, metaphorical, 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 judgements about self
B. Does not occur exclusively during the course of schizophrenia, bipolar disorder or depressive disorder with
psychotic features, another psychotic disorder, or mutism spectrum disorde
Therapy
● Psychotherapy
○ Do not differ from schizoid
○ Patients have peculiar pattern of thinkings and some are involved in cults, strange
religious practice, occult → therapist must not ridicule or judge the belief
● Pharmacotherapy
○ Antipsychotic medication → ideas of reference, illusions, other symptoms
Dissocial/Antisocial
Definition and Epidemiology
Inability to conform to social norms that ordinarily govern many aspects of a person’s adolescent
and adult behavior

Characterized by continual antisocial or criminal acts, but the disorder is not synonymous with
criminality → lying, truancy, running away from home, thefts, fights, substance abuse, illegal
activities reported in childhood

May seem charming, often impress opposite-sex with seductive aspects of personality, manipulative

Lack of remorse for their actions, lack of conscience

12-month prevalence 0,2-3%, more common in poor urban areas and among mobile residents of
these areas, more common in males, onset before 15 yo, has a familial pattern
Diagnosis Criteria - DSM V
A. A pervasive pattern of disregard for a violation of the rights of other, occurring since age 15
years, as indicated by 3 or more of the following
1. Failure to conform to social norms with respect to lawful behaviours, as indicated by
repeatedly performing acts that are grounds for arrest
2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others of personal
profit or pleasure
3. Impulsivity or failure to plan ahead
4. Irritability and agressiveness, as indicated by repeated physical fights or assaults
5. Reckless diregard for safety of self or others
6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work
behavior or honor financial obligation
7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt,
mistreated, or stolen from another
B. Individual is at least age 18 years
C. THere is evidence of conduct disorder with onset before 15 years
Diagnosis Criteria - ICD 10
1. Callous unconcern for the feelings of others
2. Gross and persistent attitude of irresponsibility and disregard for social norms,
rules and obligations
3. Incapacity to maintain enduring relationships, though having no difficulty in
establishing them
4. Very low tolerance to frustration and a low threshold for discharge of aggression,
including violence
5. Incapacity to experience guilt and to profit from experience, particularly
punishment
6. Marked proneness to blame others, or to offer plausible rationalizations, for the
behaviour that has brought the patient into conflict with society

Associated feature: persistent irritability, conduct disorder during childhood and

adolescence
Therapy
● Psychotherapy
○ Self-help groups more useful than jails → patients lack of motivation when immobilized
○ Firm limits are essential
○ Therapist must frustrate patients’ desire to run from honest human encounters → to
overcome patients’ fear of intimacy → separating control from punishment and
separating help and confrontation from social isolation and retribution
● Pharmacotherapy
○ Anxiety, rage, depression
○ Attention-deficit/hyperactivity → methylphenidate
Borderline
Definition and Epidemiology
Ambulatory schizophrenia, as-if personality, pseudoneurotic schizophrenia,
psychotic character disorder

Between neurosis and psychosis → extraordinarily unstable affect, mood,

behavior, object relation, and self-image

1-2% of population, 2x in women

Increase prevalence of major depressive disorder, alcohol use disorders, and

substance abuse in first degree relatives
Diagnosis Criteria - DSM V
A. A pervasive pattern of instability of interpersonal relationship, self image, and affects, and
marked impulsivity, beginning by early adulthood and present in variety of context, as
indicated by 5 or more of the following
1. Frantic efforts to avoid real or imagined abandonment
2. A pattern of unstable and intense interpersonal relationship 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 2 areas that are potentially self damaging (eg spending, eating, etc)
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
6. Affective instability due to a marked reactivity to mood
7. Chronic feeling of emptiness
8. Inappropriate, intense anger or difficulty controlling anger
9. Transient, stress-related paranoid ideation or dissociative symptoms
Diagnosis Criteria - ICD 10
F60.3 Emotionally unstable personality disorder

● Marked tendency to act impulsively without consideration of the

consequences, together with affective instability
● Ability to plan ahead may be minimal
● Outbursts of intense anger often lead to violence or “behavioral
explosions” → easily precipitated when impulsive acts are criticized or
thwarted by others
F60.30 Impulsive type

● Lack impulse control

● Outbursts of violence or threatening behaviour particularly in response to criticism by others

F60.31 Borderline type

● Emotional instability
● Self-image, aims and internal preferences (including sexual) often unclear or disturbed
● Chronic feelings of emptiness
● Lability to become involved in intense and unstable relationships → repeated emotional crisis
→ excessive efforts to avoid abandonment and series of suicidal threats or acts of self-harm
Clinical Features
● Always in a state of crisis
● Mood swings → argumentative, depressed, having no feeling → unpredictable
● Self-destructive acts
● Tumultuous interpersonal relationships, cannot tolerate being alone, frantic search for
companionship
● Panphobia, pananxiety, panambivalence, chaotic sexuality
● Defense mechanism:
○ Projection (intolerable aspects of the self are projected onto another) → may
unconsciously trying to coerce therapist to act out a particular behavior
○ Splitting → love and hate therapists and others
Therapy
● Psychotherapy
○ Dialectical behavior therapy
○ Mentalization-based treatment → social construct → to be attentive to the mental states
of oneself and others
○ Transference-focused psychotherapy → clarification (patient becomes quickly aware of
his or her distortions about the therapist), confrontation (therapist points out how
transferential distortions interfere with interpersonal relations toward others)
● Pharmacotherapy
○ Antipsychotic for anger, hostility, brief psychotic episodes
○ Antidepressant → depressed moods
○ MAOIs → impulsive behavior
Histrionic
Definition and Epidemiology
Excitable and emotional and behave in colorful, dramatic, extroverted fashion

Inability to maintain deep, long-lasting attachment

High degree of attention-seeking behavior → exaggerate their thoughts and feelings, make things
sound more important than it really is, display temper tantrum, tears, and accusations when they
are not the center of attention

Seductive behaviour → coy or flirtatious, reassure themselves that they are attractive to other sex

Relationships superficial, strong dependence needs make them overly trusting and gullible

Defense mechanism → repression and dissociation → unaware of their own true feelings and cannot
explain their motivations

1-3% of population, more in woman

Diagnosis Criteria - DSM V
A. A pervasive pattern of exclusive emotionality and attention seeking, beginning by early
adulthood and present in a variety of contexts, as indicated by 5 or more of the following
1. Is uncomfortable in situation in which he or she is not the center of attention
2. Interaction with other is often characterized by inappropriate sexually seductive or
provocative behavior
3. Displays rapidly shifting and shallow expression or 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 exaggerate expression of emotion
7. Is suggestible (easily influenced by other or circumstances
8. Considers relationships to be more intimate than they actually are
Diagnosis Criteria - ICD 10
1. Self-dramatization, theatricality, exaggerated expression of emotions
2. SUggestibility, easily influenced by others or by circumstances
3. Shallow and labile affectivity
4. Continual seeking for excitement, appreciation by others, and activities in
which the patient is the centre of attention
5. Inappropriate seductiveness in appearance or behaviour
6. Over-concern with physical attractiveness

Associated features: egocentricity, self-indulgence, continuous longing for

appreciation, feelings that are easily hurt, persistent manipulative behaviour
to achieve own needs
Therapy
● Psychotherapy
○ Clarification of their inner feelings
○ Psychoanalytically oriented psychotherapy
● Pharmacotherapy → adjunctive when symptoms are targeted (eg
antidepressant for depression)
Narcissistic
Definition and Epidemiology
Characteristic: heightened sense of self-importance, lack of empathy (feign
sympathy only to achieve their own selfish need), and grandiose feelings of
uniqueness

Underneath → fragile self-esteem, vulnerable to even minor criticism

Relationships are tenuous, make others furious by their refusal to obey

conventional rules of behavior

Susceptible to depression. Interpersonal difficulties, occupational problems,

rejection, and loss

1-6% in community
Diagnosis Criteria - DSM V
A. A pervasive pattern of grandiosity (in fantasy or behaviour), need for admiration, and lack of
empathy, beginning by early adulthood and present in a variety of contexts, as indicated by 5
or more of the following
1. Has a grandiose sense of self-importance
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 orr high status people (or institution)
4. Require excessive admiration
5. Has a sense of entitlement (unreasonable expectations of especially favorable treatment
or automatic compliance with his or her expectations)
6. Is interpersonally exploitative (takes advantage of others to achieve his or her own needs)
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 him or her
9. Shows arrogant, haughty behaviours or attitude
Therapy
● Psychotherapy
○ Psychoanalytic approaches to effect change
○ Group therapy → share with others, develop empathic response
● Pharmacotherapy
○ Lithium → mood swings
○ Antidepressant → depression
Avoidant
Definition and Epidemiology
Extreme sensitivity to rejection and may lead socially withdrawn lives

Shy but not asocial and show a great desire for companionship, but need unusually strong
guarantees of uncritical acceptance (hypersensitivity to rejection)

Inferiority complex, main personality trait is timidity, lack self-confidence, may speak in self-effacing
manner

Apt to misinterpret others’ comments as derogatory or ridiculing

Rarely attain much personal advancement or exercise much authority but seem shy and eager to
please

2-3% of population, infants with timid temperament may be mor susceptible (activity approach
scales)
Diagnosis Criteria - DSM V
A. A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative
evaluation, beginning by early adulthood and present a variety of context, as indicated by 4 or
more of the following
1. Avoids occupation activities that involve significant interpersonal contact because of fears
criticism, disapproval, or rejection
2. Is unwilling to get involved with people unless certain of being liked
3. Shows restraint within intimate relationships because it may prove the fear of being
shamed or ridiculed
4. Is preoccupied with being criticized or rejected in social situation
5. Is inhibited in new interpersonal situation because of feelings of inadequacy
6. Views self as socially inept, personally unappealing, or inferior to others
7. Is unusually reluctant to take personal risk or to engage in any new activities because they
may prove embarrassing
Diagnosis Criteria - ICD 10
1. Persistent and pervasive feelings of tension and apprehension
2. Belief that one is socially inept, personally unappealing, or inferior to
others
3. Excessive preoccupation with being criticized or rejected in social
situations
4. Unwillingness to become involved with people unless certain of being
liked
5. Restrictions in lifestyle because of need to have physical security
6. Avoidance of social or occupational activities that involve significant
interpersonal contact because of fear of criticism, disapproval, or
rejection

Associated feature: hypersensitivity to rejection and criticism

Therapy
● Psychotherapy
○ Solidifying alliance with patients, must convey an accepting attitude toward the patient’s
fears, encourage patient to move out into the world
○ Giving assignments to exercise new social skill → careful failure can reinforce patient’s
already poor self-esteem
○ Group therapy → help understand how their sensitivity to rejection affect them and
others
○ Assertiveness training → behavior therapy → express their needs openly and to enlarge
their self-esteem
● Pharmacotherapy
○ Manage anxiety and depression → beta-blocker (hyperactivity)
Dependent
Definition and Epidemiology
Passive-dependent personality

Subordinate their own needs to those of others, get others to assume

responsibility for major areas of their lives, lack self-confidence, intense
discomfort when being alone

Oral-dependent personality dimension → dependence, pessimism, fear of

sexuality, self-doubt, passivity, suggestibility, lack of perseverance

Prefer to be submissive rather than lead

0,6% of population, more common in young children

Diagnosis Criteria - DSM V
A. 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 5 or more of the following
1. Has difficult making everyday decisions without an excessive amount of advice and reassurance from
others
2. Need other to assume responsibility for most major areas of his or her life
3. Has difficulty expressing disagreement with other because of fear of loss of support or approval
4. Has difficulty initiating project or doing things on his or her own (because lack of self confidence in
judgment or abilities rather than a lack of motivation or energy)
5. Goes to excessive length to obtain nurturance and support from other, 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
himself or herself
7. Urgently seeks another relationship as a source of care and support when a close relationships ends
8. Is unrealistically preoccupied with fear of being left to take care of himself or herself
Diagnosis Criteria - ICD 10
1. Encouraging or allowing others to make most of one’s important life
decisions
2. Subordination of one’s own needs to those of others on whon one is
dependent, and undue compliance with their wishes
3. Unwillingness to make even reasonable demands on the people one
depends on
4. Feeling uncomfortable or helpless when alone, because of exaggerated
fears of inability to care for oneself
5. Preoccupation with fears of being abandoned by a person with whon one
has a close relationship, and of being left to care for oneself
6. Limited capacity to make everyday decisions without an excessive amount
of advice and reassurance from others
Therapy
● Psychotherapy
○ Insight-oriented therapy → understand the antecedents of their behavior
○ Behavioral therapy, assertiveness training, family therapy, group therapy
○ Pitfall → therapist encourages to change dynamics of pathological relationship →
therapist must show great respect for attachment
● Pharmacotherapy
○ Anxiety and depression
Anankastic
(Obsessive-Compulsive)
Definition and Epidemiology
Characteristic: emotional constriction, orderliness, perseverance,
stubbornness and indecisiveness

Essential feature: pervasive pattern of perfectionism and inflexibility

Limited interpersonal skills, formal and serious, often lack sense of humor

Fear of making mistake, indecisive and ruminate about making decisions

2-8%, more common in men, most often in oldest siblings

Background → harsh discipline

Freud → difficulties of anal stage

Diagnosis Criteria - DSM V
A. A pervasive pattern of preoccupation with orderliness, perfectionism, and mental in
interpersonala control, at the expense of flexibility, openness and efficiency, beginning by early
adulthood and present in a variety of context, as indicated by 4 or more of the following
1. Is preoccupied with details, rules list, order, organization, or schedules to the extent that the major point
of the activity is lost
2. Show perfectionism that interferes with completion (unable to complete project because overly strict
standard are not met)
3. Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not
accounted for obvious economic necessity)
4. Is overconscious, scrupulous, and inflexible about matters off morality, ethics, or values
5. Is unable to discard worn-out or worthless object even when they have no sentimental value
6. Is reluctant to delegate tasks or work with other unless they submit to exactly his or her way of doing
things
7. Adopts a miserly spending style towards both self and other money is viewed as something to be
hoarded for future catastrophes
8. Shows rigidity and stubborness
Diagnosis Criteria - ICD 10
1. Feelings of excessive doubt and caution
2. Preoccupation with details, rules, lists, order, organization or schedule
3. Perfectionism that interferes with task completion
4. Excessive conscientiousness, scrupulousness, and undue preoccupation
with productivity to the exclusion of pleasure and interpersonal
relationship
5. Excessive pedantry and adherence to social conventions
6. Rigidity and stubbornness
7. Unreasonable insistence by the patient that others submit to exactly his
or her way of doing things, or unreasonable reluctance to allow other do
things
8. Intrusion of insistent and unwelcome thoughts or impulses
Therapy
● Psychotherapy
○ Patient often aware of their suffering → seek treatment
○ Patient vallue free association and no-directive therapy highly
○ Group therapy and behaviour therapy → interrupt the patient in the midst of their
maladaptive interactions
○ Preventing the completion of their habitual behavior → susceptible to learning new
coping strategies
● Pharmacotherapy
○ Clonazepam → OCD
○ Clomipramine 60-80mg → obsessive compulsive signs and symptoms
Mixed and Other
Personality Type
Diagnosis Criteria - ICD 10
F61.0 Mixed Personality Disorder
● With features of several of the disorders in F60.-
● Without a predominant set of symptoms that would allow a more specific
diagnosis

F61.1 Troublesome Personality Changes

● Not classifiable in F60.- or F62.- and regarded as secondary to a main

diagnosis of a coexisting affective disorder
Enduring Personality
Changes
Group of personality and behaviour which develop following catastrophic or
excessive prolonged stress, or following a severe psychiatric illness in people
with no previous personality disorder

Exclude personality and behavioral disorder due to brain disease, damage,

and dysfunction (F07.-)
F62.0 Enduring Personality Changes After Catastrophic Experience
Personality change should be enduring and manifest as inflexible and
maladaptive features leading to an impairment in interpersonal, social and
occupational functioning

1. A hostile or mistrustful attitude towards the world

2. Social withdrawal
3. Feelings of emptiness or hopelessness
4. A chronic feeling of being “on edge”, as if constantly threatened
5. Estrangement

Onset 2 years, not attributable to PTSD

F62.0 Enduring Personality Changes After Psychiatric Illness
1. Excessive dependence on and a demanding attitude towards others
2. Conviction of being changed or stigmatized by the preceding illness, leading to an
inability to form and maintain close and confiding personal relationship and to
social isolation
3. Passivity, reduced interests, and diminished involvement in leisure activities
4. Persistent complaints of being ill, which may be associated with hypochondriacal
claims and illness behaviour
5. Dysphoric or labile mood, not due to the presence of a current mental disorder or
antecedent mental disorder with residual affective symptoms
6. Significant impairment in social and occupational functioning compared with the
premorbid situation

Onset 2 years
Impulse Disorder
Definition
Inability to resist an intense impulse, drive, or temptation to perform a
particular act that is obviously harmful to self or others, or both.

● Before the event individual usually experiences mounting tension and

arousal, mingled with conscious anticipatory pleasure
● Completing action brings immediate gratification and relief
● Within a variable time afterward individual experience remorse, guilt,
self-reproach, and dread
Etiology
● Psychodynamic factors
○ Diminished ego defense against the drives or instinctual drives → buildup → decrease
heightened tension with impulse
○ Impulsive behavior → weak superego and weak ego structures + psychic trauma
produced by childhood deprivation
○ Impulsive behavior → attempts to master anxiety, guilt, depression, and other painful
affect
○ Incomplete sense of self → do not receive validating and affirming response they seek
from persons in significant relationship with them, the self might fragment → try to regain
sense of wholeness or cohesion in self
○ Trying to recapture primitive maternal relationship
● Psychosocial
○ Improper models for identification (eg parents)
○ Exposure to violence at home, alcohol abuse, promiscuity, antisocial behavior
● Biological factors
○ Brain regions: limbic system → impulsive and violent activity
○ Low 5-HIAA
Classification
DSM V (Disruptive, Impulse-Control, and ICD 10 (Habit and Impulse Disorder)
Conduct DIsorder)
● F63.0 Pathological gambling
● Oppositional defiant disorder (F91.3) ● F63.1 Pathological fire-setting [pyromania]
● F63.2 Pathological stealing [kleptomania]
● Intermittent explosive disorder
● F63.3 Trichotillomania
● Conduct disorder (F91) ● F63.8 Other habit and impulse disorder
● Pyromania ○ Include: intermittent explosive
● Kleptomania (behaviour) disorder
● F63.9 Habit and Impulse disorder, unspecified
Pathological Gambling
Definition
Frequent, repeated episodes of gambling which dominate the individual’s life
to the detriment of social, occupational, material, and family values and
commitments

May put their job at risk, acquire large debts, and lie or break the law to obtain
money or evade payment of debts

Intense urge to gamble which is difficult to control, preoccupation with ideas

and images of the act of gambling
Diagnosis Criteria - ICD 10
Persistently repeated gambling which continues and often increase despite
adverse social consequences such as impoverishment, impaired family
relationships, and disruption of personal life
Pyromania
Definition and Epidemiology
Recurrent, deliberate, and purposeful setting of fires

Fascination with, interest in, curiosity about, or attraction to fire and activities
and equipment associated with firefighting

Differs from arson that does this for financial gain, revenge, or other reasons
and is planned beforehand

Far more often in male, 40% less than 18 yo

Etiology
● Psychosocial
○ Freud → fire as symbol of sexuality → warmth, phallus in activity
○ Abnormal craving for power and social prestige, prove themselves brave
○ Vent accumulated rage over frustration caused by a sense of social, physical, or sexual
inferiority
○ Several studies noted fathers of patients were absent from home → wish for absent
father to return home to rescue
● Biological factors → low 5-HIAA and MHPG (serotonin and adrenergic
involvement)
Diagnosis Criteria - DSM V
A. Deliberate purposeful fire setting on more than 1 occasion
B. Tension or effective arousal before act
C. Fascination with, interest in, curiosity about, or attraction to fire and it’s
situational context
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 coneceal 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 judgement
F. The fire setting is not better explained by conduct disorder, a manic
episode or antisocial personality disorder
Diagnostic criteria - ICD 10
1. Repeated fire-setting without any obvious motive such as monetary gain,
revenge, or political extremism
2. An intense interest in watching fires burn
3. Reported feelings of increasing tension before the act, and intense
excitement immediately after it has been carried out
Therapy
Behavioral approaches should be tried

Intensive interventions as therapeutic and preventive measures, not as

punishment

Family therapy in children and adolescents

Kleptomania
Definition
Recurrent failure to resist impulses to steal objects not needed for personal
use or for monetary value (object taken often given away, returned
surreptitiously, or kept and hidden)

Estimated 0.6% prevalence, male:female = 1:3, onset generally is late

adolescence
Etiology
● Psychosocial factors
○ Appear in times of significant stress → losses, separations → aggressive impulses →
symbolism of stolen object, victim of the theft
○ Central feeling of being neglected, injured, or unwanted
○ 7 categories of stealing in acting-out children → as a means of restoring the lost
mother-child relationship; as an aggressive act; as a defense against fear of being
damage; as a means of seeking punishment; as a means of restoring or adding to
self-esteem; in connection with, and as a reaction to, a family secret; as excitement and a
substitute for a sexual act
● Biological factors → = impulse disorder
Diagnosis Criteria - DSM V
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 no 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
Diagnosis Criteria - ICD 10
There is an increasing sense of tension before, and a sense of gratification
during and immediately after, the act.

Although some effort at concealment is usually made, not all the

opportunities for this are taken

The theft is a solitary act, not carried out with an accomplice

Individual may express anxiety, despondency, and guilt between episodes of

stealing, but this doesn’t prevent repetition
Therapy
● Insight-oriented psychotherapy → for guilt and shame → increase
motivation to change their behavior
● Psychoanalysis
● Behavior therapy → systematic desensitization, aversive conditioning,
combination of aversive conditioning and altered social continencies
● SSRI → fluoxetine & fluvoxamine
Trichotillomania
Diagnosis Criteria - DSM V
Obsessive-compulsive and related disorder

A. Recurrent pulling out of one’s hair resulting in hair loss

B. Repeated attempt to decrease or stop hair pulling
C. The hair pulling causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning
D. The hair pulling or hair loss is not attributable to another medical
condition
E. The hair pulling is not better explained by the symptoms of another
mental disorder
Diagnosis Criteria - ICD 10
Noticeable hair loss due to a recurrent failure to resist impulses to pull out
hairs

Usually preceded by mounting tension and is followed by a sense of relief or

gratification

Diagnosis should not be made if there is a preexisting inflammation of the

skin, or if the hair-pulling is in response to a delusion or a hallucination
Intermittent Explosive
Disorder
Definition and Epidemiology
Discrete episodes of losing control of aggressive impulses → assault

Out of proportion to any stressors that may have helped elicit the episodes

Patient usually show genuine regret or self-reproach and absent signs of

impulsivity or aggressiveness between episodes

More common in men than women, usually appears between late

adolescence and early adulthood
Etiology
● Psychodynamic factors
○ Defense against narcissistic injurious events → rage outbursts serve as interpersonal
distance and protect against further narcissistic injury
● Psychosocial factors
○ Typical patient → physically large, but dependent men whose sense of masculine identity
is poor, sense of being useless and impotent or of being unable to change the
environment
○ Childhood environment → alcohol dependence, beatings, threats to life
● Biological factors
○ Limbic system involved in most cases of episodic violence
○ Decrease serotonergic transmission
Diagnosis Criteria - DSM V
Diagnosis Criteria - ICD 10
Other habit and impulse disorders

● Persistently repeated maladaptive behaviour that are not secondary to a

recognized psychiatric syndrome
● Appears that there is repeated failure to resist impulses to carry out the
behaviour
● There is a prodromal period of tension with a feeling of release at the
time of the act
Therapy
Combined pharmacological and psychotherapeutic approach

● Psychotherapy
○ group therapy, family therapy
○ goal→ to have the patient recognize and verbalize the thoughts or feelings that precede
the explosive outbursts instead of acting them out
● Pharmacotherapy
○ Lithium, carbamazepine, valproate, phenytoin
Other
Internet Compulsion
Internet addiction

Spend almost all their walking hours at the computer terminal, repetitive and
constant, unable to resist strong urges to use the computer or to surf the web

Interferes with social relations and work performance

Mobile or Cell Phone Compulsion
Use mobile phones to call others

May have underlying conflicts such as fear of being alone, need to satisfy
unconscious dependency needs, undoing a hostile wish toward a loved one
Repetitive Self-Mutilation
Repeatedly cut themselves or do damage to their body

Parasuicidal behavior common in borderline personality disorder

Non-suicidal self injury → repeatedly damage their bodies but do not wish to
die, contrast with persons who harm themselves with true suicidal intent

Secondary gain to self-injurious behaviour

Inflicting bodily pain → release endorphine or iraise dopamin → euthymic or

elated mood
Gender Identity
Disorder
Definition
Person with marked incongruence between experienced gender and the one
they were assigned at birth

Gender identity → sense one has a being male or female, which corresponds
most often to the persons’ anatomical sex

Transgender → general term to refer tose who identify with a gender different
from the one they were born

● Transsexual → want to have the body of another sex

● Genderqueer → feel they are between genders (both or neither)
● Crossdressers → wear clothing associated with another gender but
maintain a gender identity same with their assgined gender
Etiology
● Biological
○ Resting state of tissue is initially female → male is produced only if androgen is introduced (Y
chromosome) → masculinity, maleness
○ Gender identity may result more from postnatal life
○ Brain organization theory → masculinization or feminization of the brain in utero
● Psychosocial
○ Children may develop sense of their gender identity around age 3
○ Gender identity influenced by interaction of children’s temprament and parent’s qualities and attitudes
○ Freud → conflicts in Oedipal triangle → whatever interferes with a child’s loving the opposite-sex parent
and identifying with the same-sex parent interferes with normal gender identity development
○ Mother-child relationship in first year of life → mother facilitate thier children’s awareness of and pride
in their gender
○ Children are given message they would be more valued if they adopted gender identity of opposite sex
○ Father is prototype of future love objects for girls and model for male identification for boys
Diagnosis Criteria - DSM V
Gender Dysphoria in Children

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at

least 6 months duration, as manifested by at least 6 of the following (1 must be criterion A1)
1. A strong desire to be of the other gender or an insistence that he or she is the other gender (or some
alternative gender different from one’s assigned gender)
2. In boys → strong preference for crossdressing or simulating female attire; in girls → a strong preference for
wearing of typical feminine clothing
3. A strong preference for cross-gender roles in make-believe play or fantasy play
4. A strong preferece for the toys, game, or activities stereotypically used by other gender
5. A strong preference for playmates of the other gender
6. In boys → strong rejection of typically masculine toys, game, and activities and strong avoidance of
rough-and-tumble play; in girls → strong rejection of typically feminine toys, game, and activities
7. A strong dislike of one’s sexual anatomy
8. A strong desire for the primary and/or secondary sex characteristic that match one’s experienced gender
B. The condition is associated with clinicaly significant distress on impairment in social, school, or other important
areas of functioning
Gender dysphoria in Adolescents-Adult

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of

at least 6 months duration, as manifested by at least 2 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 characteristic because of
a marked incongruence with one experienced/expressed gender
3. A strong desire for the primaro and/or secondary sex characteristic that of the other
gender
4. The strong desire to be of the other gender
5. A strong desire to be treated as the other gender
6. A strong conviction that one has the typical feelings and reactions of the other gender
B. The condition is associated with clinically significant distress on impairment in social,
occupational, or other important areas of functioning
Diagnosis Criteria - ICD 10
F64.0 Transsexualism

● Desire to live and be accepted as a member of the opposite sex

● Sense of discomfort with, or inappropriateness of one’s anatomic sex
● A wish to have hormonal treatment and surgery to make one’s body as
congruent as possible with the preferred sex
● At least 2 years
● Not a symptom of another mental disorder
F64.1 Dual-Role Transvestism

● Wearing of clothes of the opposite sex for part of the individual’s

existence in order to enjoy the temporary experience of membership of
the opposite sex
● No desire for a more permanent sex change or associated surgical
reassignment
● No sexual excitement accompanies the cross-dressing, which
distinguishes the disorder from fetihistic transvestism (F65.1)
F64.2 Gender Identity Disorder of Childhood

● Pervasive and persistent desire to be the opposite sex to that assigned, together with an
intense rejection of the behaviour, attributes, and/or attire of the assigned sex
● Usually during preschool years, before puberty
● Deny being disturbed by it, although they may be distressed by the conflict with the
expectations of their family or peers, and by the teasing and/or rejection to which they may be
subjected
● Boys: cross-dressing (no sexual excitement), strong desire to participate in games and pastimes
of girls, girls are regularly their playmates, ostracism
● Girls: preoccupation with behaviour stereotypically associated with opposite sex, male
companions, avid interest in sports and rough-and-tumble play
● Repudiation of the anatomic structures of assigned sex
Treatment
● Children
○ Individual, family, group therapy → exploring their gendered interests and identities
○ Reparative or conversion therapy → attempts to change a person’s gender identity or
sexual orientation
● Adolescent
○ Psychotherapy
○ Puberty-blocking medications → GnRH agonists → temporarily block release of hormones
→ time for adolescent and families time to reflect on the best options moving forward
● Adults
○ Psychotherapy → explore gender issues
○ Hormonal treatment, surgical treatment → decrease depression and improve quality of
life
Disorders of Sexual
Preference
Definition
Paraphilic disorder (DSM V)

Paraphilias → act that are deviations from normal sexual behaviours, but are
necessary for some persons to experience arousal and orgasm

Individual has deviant fantasy or impulse → expressed behaviourally

Pathognomonic element: fantasy, sexual arousal and orgasm → behaviour

Major functions of human sexual behavior → assist bonding, create mutual

pleasure in cooperation with a partner, to express and enhance love between
2 persons, to procreate → entail divergent behaviors
Epidemiology
Small percentage of population
Etiology
● Psychosocial factors
○ Failed to complete normal developmental process toward sexual adjustment
○ What distinguishes the paraphilias is the method chosen by a person to cope with the anxiety
caused by the threat of castration by the father and separation from mother
■ Exhibitionism and voyeurism → reaction of victim or arousal of the voyeur reassures the
paraphilic person the penis is intact
■ Shoe fetish → denies women have lost their penises through castration by attaching libido
to phallic object, the shoe, which symbolizes female penis
○ Failure to resolve oedipal crisis by identifying with father/mother-aggressor → improper
identification with opposite-sex parent or in an improper choice of object for libido cathexis
■ Transsexualism, transvestic fetishism → identification with opposite-sex parent
○ Pedophilia and sexual sadism → need to dominate and control their victims to compensate
feelings of powerlessness during oedipal crisis
○ Masochist overcome their fear of injury and sense of powerlessness by showing they are
impervious to harm
○ Early experiences → first shared sexual experience → eg. molestation as a child
● Biological factors → studies → patients may have positive organic findings
○ Abnormal hormone level
○ Hard or soft neurological signs
○ Chromosomal abnormalities
○ Seizures
○ Dyslexia
○ Abnormal EEG
○ Major mental disorders
○ Mental handicap
Classification
DSM V (Paraphilic Disorders) ICD 10 (Disorders of sexual preference)

● Voyeuristic Disorder ● F65.0 Fetihism

● Exhibitionistic Disorder ● F65.1 Fetihistic Transvestism
● F65.2 Exhibitionism
● Frotteuristic Disorder
● F65.3 Voyeurism
● Sexual Masochism Disorder ● F65.4 Paedophilia
● Sexual Sadism Disorder ● F65.5 Sadomasochism
● Pedophilic Disorder ● F65.6 Multiple disorders of sexual preference
● Fetihistic Disorder ● F65.8 other disorder of sexual preference
● F65.9 Disorder of sexual preference,
● Transvestic Disorder
unspecified
F65.0 Fetishism
ICD 10 DSM V

● Reliance on some non-living object as a A. Over a period of at least 6 months, recurrent

stimulus for sexual arousal and sexual and intense sexual arousal from either the use
of nonliving objects or a highly specific focus on
gratification (eg. articles of clothing,
nongenital body part as manifested by
footware) fantasies, urges, or behaviors
● Fetish objects vary in their importance B. The fantasies, sexual urges, or behaviour cause
to the individual → simply enhance clinically significant distress or impairment in
sexual excitement achieved in ordinary social occupational, or other important areas
of functioning
ways
C. The fetish objects are not limited to articles of
● Fetish is the most important source of
clothing used in crossdressing (as in
sexual stimulation or essential for transvestism disorder) or device specifically
satisfactory sexual response designed for the purpose of tactile genital
● Only males stimulation
F65.1 Fetishistic Transvestism
ICD 10 DSM V (Transvestic DIsorder)

● Wearing of clothes of the opposite sex A. Over the period of at least 6 months,
principally to obtain sexual excitement recurrent and intense sexual arousal
● Clothing not only worn but worn also to from cross-dressing, as manifested by
create the appearance of a person of fantasies, urges, or behaviour
the opposite sex (DD F65.0) B. The fantasies, sexual urges, or
● Clear association with sexual arousal behaviour cause clinically significant
and the strong desire to remove the distress or impairment in social
clothing once orgasm occurs and sexual occupational or other important areas
arousal declines (DD transsexual of functioning
transvestism)
● Commonly reported as an earlier phase
by transsexual and probably represent a
stage in development of transsexualism
F65.2 Exhibitionism
ICD 10 DSM V

● Recurrent or persistent tendency to A. Over a period of at least 6 months,

expose the genitalia to strangers recurrent and intense sexual arousal
without inviting or intending closer from the exposure of one’s genitals to
contact an unsuspecting person, as manifested
● Sexual excitement at the time of the by fantasies, urges, behaviours
exposure and the act is commonly B. The individual has acted on these sexual
followed by masturbation urges with a nonconsenting person, or
● Only manifest at time of stress the sexual urges of fantasies cause
● Limited to heterosexual males who clinically significant distress or
expose to females impairment in social, occupational, or
● Find their urges difficult to control and other important areas of functioning
ego-alien
● If witness appears shocked, frightened
F65.3 Voyeurism
ICD 10 DSM V

● Recurrent persistent tendency to look at A. Over a period of at least 6 months,

people engaging in sexual or intimate recurrent and intense sexual arousal
behaviour such as undressing from observing an unsuspecting person
● Usually leads to sexual excitement and who is naked, in the process of
masturbation and is carried out without discrobing or engaging in sexual activity,
the observed people being aware as manifested by fantasies, urges,
behaviours
B. Individual acted on these urges with
nonconsenting person, or urges cause
significant distress or dysfunction
C. At least 18 years of age
F65.4 Paedophilia
ICD 10 DSM V

● Sexual preference for children, usually of A. Over period of at least 6 months,

prepubertal or early pubertal age recurrent intense sexually arousal
● Rarely identified in women
fantasies, sexual urges, or behaviours
● Contact between adults and sexually mature
adolescents are not associated with involving sexual activity with prepuber
paedophilia child or children (generally are 13 years
● If perpetrator is himself an adolescent does not or younger)
establish the presence of persistent tendency B. The individual has acted on these sexual
required for diagnosis
urges, or the sexual urges of fantasies
● Include men who retain preference for adult
cause marked distress or interpersonal
sex partners but because they are chronically
frustrated in achieving appropriate contacts difficulty
habitually turn to children as substitute C. The individual is at least age 16 years
and at least 5 years older than the child
in criterion A
F65.5 Sadomasochism
ICD 10 DSM V

● Preference for sexual activity that A. Over a period of at least 6 months,

involves bondage or infliction of pain or recurrent, intense sexual arousal from:
humiliation a. Sexual sadism → the physical or
○ Recipient → masochism physiological suffering from another
○ Provider → sadism person, as manifested by fantasies,
● Activity is the most important source of urges, and behaviours → has acted on
with nonconsenting person
stimulation or necessary for sexual
b. Sexual masochism → the act of being
gratification humiliated, beaten, bound, or otherwise
● Violence is necessary for erotic arousal made to suffer as manifested by
fantasies, urges, and behaviours
B. The fantasies, sexual urges, or behaviour
cause clinically significant distress or
impairment in social, occupation, or other
important areas of functioning
F65.6 Multiple disorder of sexual preference
Sometimes more than one disorder of sexual preference occurs in one person
and none has clear precedence

Most common combination: fetihism, transvestism, and sadomasochism

F65.8 Other
Frotteuristic Disorder → DSM V

A. Over a period of at least 6 months, recurrent and intense sexual arousal

from touching or rubbing against a nonconsenting person, as manifested
by fantasies, urges, behaviours
B. The individual as acted on these sexual urges with a nonconsenting
person, or the sexual urges of fantasies cause clinically significant distress
or impairment in social, occupational, or other important areas of
functioning

Other: sexual activity with animals, strangulation or anoxia, necorphili, etc

Therapy
5 types of psychiatric intervention:

● External control → prison, supervisors

● Reduction of sexual drives → antiandrogen
● Treatment of comorbid conditions
● CBT → modify behavior to make it socially acceptable → social skills
training, sex education, cognitive restructuring, development of victim
empathy
● Dynamic psychotherapy → insight-oriented psychotherapy, understand
events that caused paraphilia to develop
Psychological and Behavioral
Disorders associated with
Sexual Development and
Orientation
Fifth Character
Variations of sexual development or orientation that may be problematic for
the individual:

● F66.x0 Heterosexual
● F66.x1 Homosexual
● F66.x2 Bisexual → to be used only when there is clear evidence of sexual
attraction to members of both sex
● F66.8 Other, including prepubertal
F66.0 Sexual Maturation Disorder
Uncertainty about his or her gender identity or sexual orientation → cause
anxiety and depression

Most commonly occurs in adolescent → not certain whether they are

homosexual, heterosexual, or bisexual in orientation

May be in individuals who after a period of apparently stable sexual

orientation find that their sexual orientation is changing
F66.1 Egodystonic Sexual Orientation
Gender identity or sexual preference is not in doubt but the individual wishes
it were different because of associated psychological and behavioral disorders
and may seek treatment in order to change it
F66.2 Sexual Relationship Disorder
Gender identity or sexual preference abnormality is responsible for difficulties
in forming or maintaining a relationship with a sexual partner