CLUSTER C PERSONALITY

DISORDERS

Presenter- Dr. Subhendu Sekhar Dhar

 OUTLINE

• INTRODUCTION
• DEFINITION OF PERSONALITY DISORDER
• CLUSTERS
• AVOIDANT PERSONALITY DISORDER
• DEPENDENT PERSONALITY DISORDER
• OBSESSIVE-COMPULSIVE PERSONALITY DISORDER
• SUMMARY
• REFERENCES
 INTRODUCTION

PERSONALITY
• The understanding of personality and its disorders is what distinguishes
psychiatry fundamentally from all other branches of medicine.

• A person is a self-aware human being, not a machine-like object that lacks self-
awareness.

• Personality refers to all the ways in which someone shapes and adapts in a
unique way to ever-changing internal and external environments.
 DEFINITION OF PERSONALITY DISORDER

• Severe disturbance in the characterological constitution and behavioural

tendencies of the individual, usually involving several areas of the personality,
and nearly always associated with considerable personal and social disruption.
(ICD-10)

• Enduring pattern of inner experience and behaviour that deviates significantly

from the expectation of the individual's cultural standards; is rigidly pervasive;
has an onset in adolescence or early adulthood; is stable over time, and leads to
unhappiness or impairment; and manifests in at least two of the following four
areas: Cognition, Affectivity, Interpersonal function and Impulse control.
(DSM-5)
 CLUSTERS

• The DSM-5 organizes 10 personality disorders into 3 groups, or clusters, based

on shared key features.

• Cluster A includes 3 disorders with odd, aloof features.

Paranoid, Schizoid, and Schizotypal.
• Cluster B includes 4 disorders with dramatic, impulsive, and erratic features.
Borderline, Antisocial, Narcissistic, and Histrionic.
• Cluster C includes 3 disorders sharing anxious and fearful features.
Avoidant, Dependent, and Obsessive-Compulsive.
 AVOIDANT (ANXIOUS) PERSONALITY DISORDER

• The patient with avoidant personality is essentially a shy, inhibited person who
has feelings of inadequacy and low self-esteem.
• These patients are hypersensitive to perceived
criticism, but have the capacity to develop
appropriate relationships if they feel safe and
accepted.
• They may lead socially withdrawn lives.
• These people are commonly described as
having an inferiority complex.
 EPIDEMIOLOGY

• Prevalence rates of 2 - 3 % in the general population.

• 10 % for psychiatric outpatients.
• This disorder is equally frequent in males and females.
• Infants classified as having a timid temperament is more susceptible to the
disorder.
 DIAGNOSTIC CRITERIA (DSM-5)

• A pervasive pattern of Social inhibition, Feelings of inadequacy, Extreme sensitivity to

negative evaluation, beginning by early childhood.
• Requires at least 4:
1. Avoids occupational activities that involve significant 5. Inhibited in new social situations because of feelings
social contact, due to fears of disapproval or rejection. of inadequacy.

2. Unwilling to deal with people unless sure of being 6. Views themselves as socially inept, personally
liked. unappealing, or inferior to others.

3. Restraint within intimate relationships due to fear of 7. Unusually reluctant to take risks or to engage in new
being shamed or ridiculed. activities because they may prove embarrassing.

4. Preoccupied with being criticized or rejected in social

situations.
 DIAGNOSTIC CRITERIA (ICD-10)

• Avoidant PD characterized by at least 3 of the following:

a. persistent and pervasive feelings of tension and apprehension;

b. belief that one is socially inept, personally unappealing, or inferior to others;
c. excessive preoccupation with being criticized or rejected in social situations;
d. unwillingness to become involved with people unless certain of being liked;
e. restrictions in lifestyle because of need to have physical security;
f. avoidance of social or occupational activities that involve significant interpersonal
contact because of fear of criticism, disapproval, or rejection.

• Associated features may include hypersensitivity to rejection and criticism.

 AVOIDANT PERSONALITY DISORDER

COMPLICATIONS: Social Phobia.

COMORBIDITY: These patients are at increased risk for Mood and Anxiety
Disorders (especially Social Phobia, generalized type). About 25-50% have Panic
Disorder, 10-25% have Generalized Anxiety Disorder, 20-25% have an Eating
Disorder, and more than 33% have Body Dysmorphic Disorder (Alden LE et al.
2002). The most common co-occurring disorders are Schizotypal, Schizoid,
Paranoid, Dependent, and Borderline.
IMPAIRMENT: Can be severe; typically includes occupational and social
difficulties.
 DIFFERENTIAL DIAGNOSIS

Social Phobia Very difficult to distinguish. In Social Phobia, specific situations rather
than interpersonal contact are avoided.

Panic Disorder with Manifests avoidance usually after the onset of panic attacks.
Agoraphobia

Schizotypal and Social isolation of avoidant personalities is accompanied by the desire for
Schizoid PD social relations, which is not observed in Schizoid and Schizotypal PD

Paranoid PD Includes guarded attitude, preoccupation with hidden meanings, and

conspiratorial explanations of benign events

Dependent PD Is focused on being taken care of rather than on the fear of negative
evaluation
 COURSE & PROGNOSIS

• Many persons with Avoidant PD are able to function in a protected

environment.
• Some live their lives surrounded only by family members.
• If their support system fails, they are subject to depression, anxiety & anger.
• Phobic avoidance is common.
• Pts. with Avoidant PD give histories of social phobia or incur social phobia in the
course of their illness.
• Avoidant PD have chronic and persistent course.
 TREATMENT

PSYCHOTHERAPY: There have actually been a couple of studies that have

examined the effects of psychotherapy for Avoidant PD. Social Skills Training &
Exposure Therapy are helpful.
One found that 20 sessions of Cognitive Behavioral Therapy (CBT) brought some
improvement in symptoms, and was superior to 20 sessions of Psychodynamic
Psychotherapy (PP) (Emmelkamp PM et al. 2006).
Another study found that 40 sessions of CBT was equally effective to 40 sessions
of PP. (Svartberg M et al. 2004).
PHARMACOTHERAPY: Used to manage anxiety & depression associated with
disorder. Some pts. are helped by Beta adrenergic receptor antagonists (Atenolol)
to manage autonomic nervous system hyperactivity.
 DEPENDENT PERSONALITY DISORDER

• Persons with Dependent PD subordinate their own needs to those of others.

• Get others to assume responsibility for major areas of their lives.
• Has difficulty making everyday decisions without
an excessive amount of advice and reassurance
from others.
• Lack self-confidence.
• Experience intense discomfort when
alone for more than a brief period.
 EPIDEMIOLOGY

• Prevalence rates of 0.6 – 3.7% in the general population.

• Female > Male.
• More common in younger children than in older ones.
• Person with chronic physical illness in childhood may be most susceptible to the
disorder.
 DIAGNOSTIC CRITERIA (DSM-5)

• 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 difficulty making everyday decisions without an 5. goes to excessive lengths to obtain nurturance and
excessive amount of advice and reassurance from support from others, to the point of volunteering to do
others things that are unpleasant
2. needs others to assume responsibility for most major 6. feels uncomfortable or helpless when alone because
areas of his or her life of exaggerated fears of being unable to care for himself
or herself
3. has difficulty expressing disagreement with others 7. urgently seeks another relationship as a source of care
because of fear of loss of support or approval. and support when a close relationship ends
Note: Do not include realistic fears of retribution.
4. has difficulty initiating projects or doing things on his 8. is unrealistically preoccupied with fears of being left
or her own to take care of himself or herself
 DIAGNOSTIC CRITERIA (ICD-10)
• Dependent PD characterized by at least 3 of the following:
a. encouraging or allowing others to make most of one’s important life decisions;
b. subordination of one’s own needs to those of others on whom one is dependent,
and undue compliance with their wishes;
c. unwillingness to make even reasonable demands on the people one depends on;
d. feeling uncomfortable or helpless when alone, because of exaggerated fears of
inability to care for oneself;
e. preoccupation with fears of being abandoned by a person with whom one has a
close relationship, and of being left to care for oneself;
f. limited capacity to make everyday decisions without an excessive amount of
advice and reassurance from others.
• Associated features may include perceiving oneself as helpless, incompetent,
and lacking stamina.
 DEPENDENT PERSONALITY DISORDER

COMPLICATIONS: Mood Disorders, Anxiety Disorders, Adjustment Disorder,

Social Phobia. Low socioeconomic status, poor family and marital functioning.
COMORBIDITY: Eating Disorders, Anxiety Disorders, Somatoform Disorders, and
other Personality Disorders (Histrionic, Avoidant, and Borderline). About 30% of
these individuals can be diagnosed with Depression, over 10% with Bipolar
Disorder, and about 7% have Dysthymia (Overholser JC 1996).
IMPAIRMENT: Frequently only mild; typically includes interpersonal relationships
and occupational functioning if independence is required.
 DIFFERENTIAL DIAGNOSIS

Mood/Anxiety These dependency behaviors would be expected to stop once the

Disorders/General underlying illness resolves.
medical conditions
Borderline PD Usually have a strong fear of being abandoned, but will tend to react
with feelings of rage and emotional emptiness and demands as
opposed to increasing appeasement. Submissiveness seen with
dependent personalities
Histrionic PD Tend to gain attention from others through dramatic and flamboyant
behavior, as opposed to people with Dependent Personality Disorder,
who will be more self-effacing and docile.
Avoidant PD Social isolation because of the fear of negative evaluation as opposed
to clinging and submissive behavior of dependent personalities
 COURSE & PROGNOSIS

• Little is known about the course of Dependent PD.

• Occupational functioning tends to be impaired because the person can’t act
independently & without close supervision.
• Social relationships are limited to those on whom they can depend.
• Risk of MDD if they lose the person on whom they depend.
• With treatment the prognosis is favourable.
 TREATMENT

PSYCHOTHERAPY: Insight-oriented therapies enable patients to understand the

antecedents of their behaviour, become more independent, assertive & self-
reliant.
Behavioral therapy, Assertiveness training, Family therapy & Group therapy have
been used with successful outcomes in many cases.

PHARMACOTHERAPY: Medications would not be expected to help very much for

the core symptoms of Dependent Personality Disorder, but will often be used to
treat any associated psychiatric conditions.
 OBSESSIVE-COMPULSIVE PERSONALITY DISORDER

Characterized by a general pattern of concern with

• orderliness,
• perfectionism,
• excessive attention to details,
• mental and interpersonal control,
• a need for control over one's environment,
• at the expense of flexibility, openness to
experience and efficiency.
 EPIDEMIOLOGY

• Prevalence rates of 2- 8% in the general population.

• 8–9% of psychiatric outpatients.
• Female: Male = 1:2
• Most often in oldest siblings.
 DIAGNOSTIC CRITERIA (DSM-5)
• A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and
interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by
early adulthood and present in a variety of contexts, as indicated by 4 or more of the
following:
1. is preoccupied with details, rules, lists, order, organization, 5. is unable to discard worn-out or worthless objects even
or schedules to the extent that the major point of the activity is when they have no sentimental value
lost
2. shows perfectionism that interferes with task completion (e.g., 6. is reluctant to delegate tasks or to work with others
is unable to complete a project because his or her own overly strict unless they submit to exactly his or her way of doing
standards are not met) things
3. is excessively devoted to work and productivity to the exclusion 7. adopts a miserly spending style toward both self and
of leisure activities and friendships (not accounted for by obvious others; money is viewed as something to be hoarded for
economic necessity) future catastrophes
4. is overconscientious, scrupulous, and inflexible about matters 8. shows rigidity and stubbornness
of morality, ethics, or values (not accounted for by cultural or
religious identification)
 DIAGNOSTIC CRITERIA (ICD-10)

• Personality disorder characterized by at least 3 of the following:

a. feelings of excessive doubt and caution;
b. preoccupation with details, rules, lists, order, organization or schedule;
c. perfectionism that interferes with task completion;
d. excessive conscientiousness, scrupulousness, and undue preoccupation with
productivity to the exclusion of pleasure and interpersonal relationships;
e. excessive pedantry and adherence to social conventions;
f. rigidity and stubbornness;
g. unreasonable insistence by the patient that others submit to exactly his or her way
of doing things, or unreasonable reluctance to allow others to do things;
h. intrusion of insistent and unwelcome thoughts or impulses.
 OBSESSIVE-COMPULSIVE PERSONALITY DISORDER

COMPLICATIONS: Distress and difficulties when confronted with new situations

that require flexibility and compromise.
COMORBIDITY: These patients are at increased risk for Major Depression and
Anxiety Disorder. There is equivocal evidence for an increased risk of Obsessive-
Compulsive Disorder.
IMPAIRMENT: Frequently severe; typically includes occupational and social
difficulties.
 DIFFERENTIAL DIAGNOSIS
• It has been found that Obsessive-Compulsive Personality Disorder and
Obsessive-Compulsive Disorder frequently coexist.
OCD
OCD is defined by the presence of true obsessions
and/or compulsions.
Ego dystonic
Symptoms of OCD tend to fluctuate in association
with the underlying anxiety
Often seek professional help to overcome the
irrational nature of their behavior and the persistent
state of anxiety they live under.
OCPD
with OCPD, the behaviors are not directed by
thoughts that are unable to control or irrational
behaviors that repeat over and over again, often with
no apparent aim.
Ego syntonic
In OCPD, the behaviors tend to be persistent and
unchanging over the long term
Usually not seek help because they don't see that
anything they are doing is particularly abnormal or
irrational.
 DIFFERENTIAL DIAGNOSIS

Schizoid PD Lack of capacity for intimacy and social isolation secondary to

emotional detachment, as opposed to devotion to work and
discomfort with emotions

Antisocial PD Material goals in antisocial behavior and criminality as opposed

to the hypermorality of obsessive personalities

Avoidant PD Isolation due to fears of disapproval or rejection, feelings of

inadequacy. In OCPD isolation results from giving priority to
work and productivity rather than relationships
 COURSE AND PROGNOSIS

• Course is variable & unpredictable.

• Some adolescents with OCPD evolve into warm, open & loving adults.
• The disorder can be the harbinger of Schizophrenia or MDD.
• Individuals with OCPD often experience a moderate level of professional success
but they are vulnerable to unexpected changes & their personal lives may
remain barren.
• Late onset Depressive disorder are common.
 TREATMENT

PSYCHOTHERAPY: Insight-oriented psychodynamic techniques and cognitive

behavioral therapy are helpful.
Specific breathing and relaxation techniques can help decrease the sense of stress
and urgency.

PHARMACOTHERAPY: SSRIs appear to help the OCPD patients with their

rigidity and compulsiveness.
 CLUSTER C PERSONALITY DISORDERS:
MANIFESTATIONS AND MANAGEMENT STRATEGIES

Personality Prominent features Experience of Problematic behaviors in Management strategies

Disorder of disorder illness medical setting
Avoidant Social inhibition due Heightened Withholds information, Provide reassurance, validate
to fears of rejection or sense of avoids questioning or concerns, encourage reporting of
humiliation inadequacy, low disagreeing with physician symptoms and concerns.
self-esteem
Dependent Excessive need to be Fear of Urgent demands for Provide reassurance, schedule
taken care of, abandonment, attention, prolongation of regular check-ups, set realistic limits
submissive and helplessness illness behavior to obtain on availability, enlist others to
clinging behavior attention and care support patient, avoid rejection of
patient.
Obsessive- Preoccupation with Fear of losing Fear of relinquishing Complete thorough history and
Compulsive orderliness, control of bodily control, excessive examinations, provide thorough
perfection, control functions and questioning and attention explanations, encourage patient
emotions to details, anger about participation in treatment.
disruption of routines
 REFERENCES
• Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 10th ed.
• Kaplan & Sadock’s Synopsis of Psychiatry
• DSM-5
• ICD-10
• Emmelkamp PM et al. Comparison of brief dynamic and cognitive-behavioural therapies in
avoidant personality disorder. British Journal of Psychiatry 2006; 189: 60-4.
• Alden LE et al. Avoidant personality disorder: current status and future directions. Journal of
Personality Disorders 2002; 16(1): 1-29.
• Svartberg M et al. Randomized, controlled trial of the effectiveness of short-term dynamic
psychotherapy and cognitive therapy for cluster C personality disorders. American Journal of
Psychiatry 2004; 161(5): 810-7.
• Overholser JC. Journal of Nervous and Mental Disease 1996; 184(1): 8-16.
• Google images.
THANKYOU