Cluster C Personality Disorders

Personality disorders are ego-syntonic behaviors that begin in childhood or adolescence and are classified into 3 clusters: A, B, and C. They can considerably interfere with a patient’s adherence to medical treatment for a variety of reasons. It is important to rule out organic causes of a mental disorder (e.g., endocrine hormone imbalances, medication adverse effects, alcohol and/or substance use, other mental health co-morbidities) before ascribing a personality disorder to a patient. Cluster C includes avoidant, dependent, and obsessive-compulsive personality disorders, which can be behaviorally described as anxious and apprehensive.

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Avoidant Personality Disorder

Key features

  • Low self-esteem 
  • Avoids social situations, interactions, or new activities out of fear of being embarrassed, ridiculed, or rejected → withdrawal not due to preference for solitude, but due to social anxiety

Risk factors

  • Associated with anxiety disorders
  • Affects women more commonly than men

Management

  • Psychotherapy (first line)
  • Pharmacotherapy for symptoms that impair functioning (e.g., anxiety, depression, mood instability)

Clinical associations

  • Very common in:
    • The general population (along with obsessive-compulsive personality disorder, which is discussed below)
    • Clinical populations (along with borderline personality disorder [cluster B])
  • Should be distinguished from:
    • The voluntary social withdrawal associated with schizoid personality disorder (cluster A)
    • Social anxiety disorder
    • Agoraphobia

Dependent Personality Disorder

Key features

  • Fear of abandonment and of being alone:
    • Tendency to stay in abusive relationships
    • Clinging and submissive behavior
  • Low self-confidence in own abilities: 
    • Needing others to take on responsibility and lead for them, e.g., with making decisions in everyday life
    • Preoccupation with fear of being “left to take care of themselves”

Risk factors

  • Associated with anxiety disorders
  • Affects women more commonly than men

Management

  • Psychotherapy (first line)
  • Pharmacotherapy for symptoms that impair functioning (e.g., anxiety, depression, mood instability)

 Clinical associations

  •  Regression is the predominant defense mechanism (i.e., the child-like need to be taken care of)
  • Should be differentiated from major depressive disorder
  • Should be differentiated from factitious disorder (i.e., the patient may sabotage their treatment in order to remain “cared for” by whomever they are dependent upon)

Obsessive-Compulsive Personality Disorder

Key features

  • Excessive devotion to work: 
    • Perfectionism: often keeping them from completing tasks on time
    • Difficulty sharing tasks and giving up control
    • Dispenses with leisure activities 
  • Rigidity:
    • Unable to accept different views of morals or the “right” way of doing something 
    • Sticking to strict rules and routines: preoccupation with planning, lists, schedules, details, etc.
  • Holding on to useless objects; excessively thrifty

Risk factors

  • Associated with anxiety disorders
  • Affects men more commonly than women

Management

  • Psychotherapy (first line)
  • Pharmacotherapy for symptoms that impair functioning (e.g., anxiety, depression, mood instability)

Clinical associations

  • Very common in the general population (along with avoidant personality disorder, which is discussed above)
  • Should be differentiated from obsessive-compulsive disorder and its related disorders (e.g., hoarding disorder) due to its lack of compulsions, as well as the ego-syntonic nature of personality disorders and the ego-dystonic nature of obsessive-compulsive and related disorders

Summary

Cluster C disorder Avoidant Dependent Obsessive-compulsive
Key features Involuntary social withdrawal due to fear of criticism and rejection
  • Submissive
  • “Clingy”
  • Needs to be taken care of
  • Rigid
  • Controlling
  • Perfectionist
Defense mechanism N/A Regression N/A
Differentials
  • Schizoid personality disorder
  • Social anxiety disorder
  • Agoraphobia
  • Major depressive disorder
  • Factitious disorder
Obsessive-compulsive disorder (OCD) and other related disorders (e.g., hoarding disorder)
Management Psychotherapy (first line) with low-dose pharmacotherapy for applicable symptoms (e.g., anxiolytics, antidepressants, mood stabilizers) Psychotherapy (first line) with low-dose pharmacotherapy for applicable symptoms (e.g., anxiolytics, antidepressants, mood stabilizers) Psychotherapy (first line) with low-dose pharmacotherapy for applicable symptoms (e.g., anxiolytics, antidepressants, mood stabilizers)
Epidemiology ♀>>♂ ♀>>♂ ♂>♀
Example A 22-year-old college student wants to try out for the volleyball team, but is afraid of not being accepted, so she stays home. A wife defers her medical treatment decisions to her husband, who has a history of spousal abuse. A 42-year-old man has an alphabetically organized baseball card collection, color-coded sock drawer, and a library numerically arranged by publication year.

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