Section Learning Objectives

• Describe the symptoms associated with each of the cluster C personality disorders.
• Describe the epidemiology of cluster C personality disorders.
• Describe the treatment for cluster C personality disorders.

9.4.1 Avoidant Personality Disorder

9.4.1.1 Clinical Description

Individuals with avoidant personality disorder display social anxiety due to feelings of inadequacy and increased sensitivity to negative evaluations (APA, 2022). The fear of being rejected and negatively evaluated drives their reluctance to engage in social situations including at work.

Individuals with this disorder have very few if any friends, despite their strong desire to establish social relationships. They actively avoid social situations in which they can establish new friendships out of the fear of being disliked or ridiculed. Similarly, they are cautious of new activities or relationships as they often exaggerate the potential negative consequences and embarrassment that may occur; this is likely a result of their ongoing preoccupation with being criticized or rejected by others.

You may recall that schizoid personality disorder is also associated with social isolation but avoidant personality disorder differs from schizoid personality disorder because while those with schizoid personality disorder do not desire social connections, those with avoidant personality very much want relationships with others. Individuals with avoidant personality disorder only avoid social relationships and settings because of their feelings of inadequacy, fear of criticism, and concern with negative evaluation.

9.4.1.2 Epidemiology

Avoidant personality disorder is estimated to occur in 2.1% of the general population and appears to be more common in women (APA, 2022).

9.4.1.3 Treatment

While many individuals with avoidant personality disorder seek out treatment to address their anxiety or depression-like symptoms, it is often difficult to keep them in treatment due to fear of rejection from the clinician. Treatment goals for avoidant personality disorder are similar to those for social anxiety disorder. CBT techniques such as identifying and challenging distressing thoughts have been effective in reducing anxiety-related symptoms (Weishaar & Beck, 2006). Behavioral treatments such as gradual exposure to various social settings, along with a combination of social skills training, have been shown to improve individuals’ confidence prior to engaging in social outings (Herbert, 2007). Anti-anxiety and antidepressant medications commonly used to treat anxiety disorders have also been used with minimal efficacy; furthermore, symptoms resume as soon as the medication is discontinued.

9.4.2 Dependent Personality Disorder

9.4.2.1 Clinical Description

Dependent personality disorder is characterized by a persistent and excessive need to be taken care of by others (APA, 2022). This intense need leads to submissive and clinging behaviors as they fear they will be abandoned or separated from their parent, spouse, or another person on whom they feel dependent. They are so dependent on this other individual that they cannot make even the smallest decisions without first consulting with them and gaining their approval or reassurance. They often allow others to assume complete responsibility for their life, making decisions in nearly all aspects of their lives. Rarely will they challenge these decisions as their fear of losing this relationship greatly outweighs their desire to express their own opinion. Should the relationship end, they experience significant feelings of helplessness and quickly and indiscriminately seek out another relationship to replace the old one (APA, 2022).

Individuals with dependent personality disorder express difficulty initiating and engaging in tasks on their own. They lack self-confidence and feel helpless when they are left to care for themselves or engage in tasks on their own. In efforts to not have to engage in tasks alone, individuals will go to great lengths to seek out support of others, often volunteering for unpleasant tasks if it means they will get the reassurance they feel they need (APA, 2022).

9.4.2.2 Epidemiology

Dependent personality disorder is estimated to occur in approximately 0.4% of the population (APA, 2022). Women are more frequently diagnosed with dependent personality disorder than men (APA, 2022).

9.4.2.3 Treatment

Unlike other personality disorders where individuals avoid treatment and are skeptical of the clinician, individuals with dependent personality disorder are likely to seek treatment and place a large emphasis on the clinician. Therefore, one of the main treatment goals for individuals with dependent personality disorder is to teach them to accept responsibility for themselves, both in and outside of treatment (Colli, Tanzilli, Dimaggio, & Lingiardi, 2014). Cognitive strategies such as challenging and changing thoughts that they are helpless and incapable of caring for themself have been minimally effective in establishing independence. Additionally, behavioral techniques such as assertiveness training have also shown some promise in teaching individuals how to express themselves within a relationship. Some argue that family or couples therapy would be particularly helpful for those with dependent personality disorder due to the dysfunctional relationship between the individual and the person on whom they are dependent; however, research on this treatment method has not yielded consistently positive results (Nichols, 2013).

9.4.3 Obsessive-Compulsive Personality Disorder 

9.4.3.1 Clinical Description

Obsessive-Compulsive Personality Disorder (OCPD) is defined by a preoccupation with orderliness, perfectionism, and control at the expense of flexibility, openness, and efficiency in everyday life (APA, 2022). Their preoccupation with details, rules, lists, orders, organizations, and schedules overshadows the larger picture of the task or activity. In fact, their self-imposed high standards and need to complete tasks perfectly often prevent these tasks from ever being completed. Their desire to complete tasks perfectly often causes them to spend excessive amounts of time on the tasks, occasionally repeating them in an attempt to reach some perfectionistic standard. Due to repetition and attention to fine detail, individuals with OCPD often feel like they do not have time to engage in leisure activities or engage in social relationships. Despite the excessive amount of time spent on activities or tasks, individuals with OCPD will not seek help from others, as they are convinced that others are incompetent and will not complete the tasks to their perfectionistic standards.

Personally, individuals with OCPD are rigid and stubborn, particularly with their morals, ethics, and values. Not only do they hold these standards for themselves, but they also expect others to have high standards, thus causing significant disruption in their social interactions. Their rigid and stubborn behaviors are also seen in their financial status, as they are known to live significantly below their means, in order to prepare financially for potential catastrophes (APA, 2022). Similarly, they may have difficulty discarding worn-out or worthless items, despite their lack of sentimental value.

Unfortunately, the term OCPD leads many to believe this is a similar disorder to OCD, but there is a distinct difference in that OCPD lacks the obsessions and/or compulsions that characterize OCD (APA, 2013). Although many individuals are diagnosed with both OCD and OCPD, research indicates that individuals with OCPD are more likely to be diagnosed with major depression, generalized anxiety disorder, or substance use disorder than OCD (APA, 2022).

9.4.3.2 Epidemiology

OCPD is the most commonly diagnosed personality disorder, occurring in 4.7% of individuals. According to the DSM-5-TR OCPD is equally prevalent in men and women (APA, 2022).

9.4.3.3 Treatment

Individuals with OCPD often seek out treatment to address their anxiety or depression-like symptoms. Cognitive techniques aimed at changing dichotomous thinking, perfectionism, and chronic worry are helpful in managing symptoms of OCPD. CBT may also be used to try to challenge and reduce perfectionistic beliefs and standards as well as rigid behaviors. They are often taught relaxation techniques to overcome the anxiety that manifests from attempts to break their rigid schedules and other behaviors.