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 disorderAvoidantDependentObsessive-compulsive
Key featuresInvoluntary social withdrawal due to fear of criticism and rejection
  • Submissive
  • “Clingy”
  • Needs to be taken care of
  • Rigid
  • Controlling
  • Perfectionist
Defense mechanismN/ARegressionN/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)
ManagementPsychotherapy (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♀>>♂♀>>♂♂>♀
ExampleA 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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