Cluster C Personality Disorders

C LUSTER C P ERSONALITY D ISORDERS

DEFINITION



A specific personality disorder is a severe disturbance in the characterological constitution and behavioral tendencies of the individual, usually involving several areas of personality, and nearly always associated with considerable personal and social disruption.



Appear in late childhood or adolescence and continues to manifest into adulthood.

P ERSONALITY

DISORDER

The DSM-IV-TR general diagnostic criteria for personality disorders are: 

A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture. The pattern is manifested in two (or more) of the following areas:



(1) cognition (i.e., ways of perceiving and interpreting self, other people, and events)



(2) affectivity (i.e., the range, intensity, lability and appropriateness of emotional response)



(3) interpersonal functioning



(4) impulse control



B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.



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 its onset can be traced back at least to adolescence or early adulthood.



E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.



F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma).

ICD 10

GENERAL CRITERIA FOR

SPECIFIC PERSONALITY DISORDER



markedly disharmonious attitudes and behaviour, involving usually several areas of functioning, e.g. affectivity, arousal, impulse control, ways of perceiving and thinking, and style of relating to others;



the abnormal behaviour pattern is enduring, of long standing, and not limited to episodes of mental illness;



the abnormal behaviour pattern is pervasive and clearly maladaptive to a broad range of personal and social situations;

CONTD



the above manifestations always appear during childhood or adolescence and continue into adulthood;



the disorder leads to considerable personal distress but this may only become apparent late in its course;



the disorder is usually, but not invariably, associated with significant problems in occupational and social performance.

CLASSIFICATION OF CLUSTER C PD:

ICD 10

DSM IV TR

Discriminating features

F60 Specific Cluster C personality anxious or fearful personality disorders disorder disorders F60.6 Anxious (avoidant) PD

Avoidant Personality disorder 301.82

avoidance

F60.7 Dependent Personality Disorder

Dependent personality disorder 301.6

Submisssive, dependent

F60.5 Anankastic personality disorder

Obsessive Compulsive personality disorder 301.50

Inflexibility, perfectionism , orderliness

A NXIOUS (AVOIDANT ) P ERSONALITY D ISORDER

HISTORY



first introduced into psychiatric classification in DSM-III (previously included among the schizoid or dependent patients)



consequence of an intense sensitivity to rejection led to the differentiation of this new personality type



hyperaesthetic shut-in individuals, phobic personalities, or active-detached personalities

D EFINITION



AVPD is a pervasive pattern of timidity, inhibition, inadequacy, and social hypersensitivity (American Psychiatric Association 2000 ).



Persons with AVPD may have a strong desire to develop close, personal relationships but feel too insecure to approach others or to express their feelings.

D IAGNOSTIC FEATURES DSM IVTR 

301.82



A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:



(1) avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection



(2) is unwilling to get involved with people unless certain of being liked



(3) shows restraint within intimate relationships because of the fear of being shamed or ridiculed



(4) is preoccupied with being criticized or rejected in social situations



(5) is inhibited in new interpersonal situations because of feelings of inadequacy



(6) views self as socially inept, personally unappealing, or inferior to others



(7) is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing

ASSOCIATED FEATURES



Fearful and tense demeanor



Fear of blushing or crying in front of others in response to criticism



Social isolation accompanied by craving social relations and fantasizing about ideal relationships with others

ICD 10

CRITERIA



persistent and pervasive feelings of tension and apprehension;



belief that one is socially inept, personally unappealing, or inferior to others;



excessive preoccupation with being criticized or rejected in social situations;



unwillingness to become involved with people unless certain of being liked;



restrictions in lifestyle because of need to have physical security;



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.



It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfy a set of

A ETIOLOGY 

familial transmission is possible, perhaps involving learning and identification, but genetic transmission may also be involved



The biological mechanisms involved in anxiety disorders and social phobia may have a role in the development of this personality disorder



hypersensitivity of brain areas involved in the separation-anxiety response and overactivity of serotonin limbic neuronal circuits may underlie the avoidant temperament trait



Psychosocial factors mediate the extent to which biological vulnerability is expressed.



Children who are belittled, criticized, and rejected by parents have decreased self-esteem, resulting in social avoidance.



These problems are reinforced and perpetuated at school and may generate the expectation of rejection from everyone

C LINICAL

FEATURES



Extremely shy, quiet, and inhibited.



Although extreme internal need for warmth and closeness present but exaggerated sensitivity to rejection by others make them distant from others and do not express wishes, demands, or opinions.



Easily hurt and humiliated by comments from others, which they misinterpret as degrading and disapproving.



Anxious, self-doubting, and insecure when speaking, often use self-defeating expressions, and try to please others.



Their tense and fearful demeanour may elicit ridicule from others which confirms their insecurity.



Concerned with reacting to scrutiny by blushing or crying, which is a cause of further interpersonal avoidance.



Choose occupations where no social interaction is needed, and strongly avoid talking in public.



The avoidant person lacks intimate relationships with friends or sexual partners unless they anticipate non-critical acceptance.



perceive themselves as inept and inadequate, and unattractive.



see others as negative and potentially harmful.



inattentive and repeatedly distracted by intrusive thoughts, but they attend intensely to signals of rejection.



low tolerance for dysphoric affects which they avoid by escaping.



Escape from reality through fantasy is their usual way of satisfying their needs and relieving frustration.

E PIDEMIOLOGY 

Prevalence < 1% in the general population, but almost 10 % in clinical populations



equally frequent in males and females.

C OURSE 

Disfiguring illness and shyness in childhood predispose children for this personality disorder.



Frequently begins in childhood with shyness and fear of strangers and new situations.



Shyness gradually dissipates in adolescence. When it evolves into AvPD, the shyness may worsen in adolescence when social and interpersonal relationships become more complex and demanding



The disorder tends to remit or to become less evident in older people.

C OMORBIDITY



These patients are at increased risk for Mood and Anxiety Disorders (especially Social Phobia, generalized type).



The most common co-occurring disorders are Schizotypal, Schizoid, Paranoid, Dependent, and Borderline.

D IFFERENTIAL D IAGNOSIS 

Avoidant Personality Disorder is very difficult to distinguish from Social Phobia (many authors believe that these are alternative labels for the same or similar condition).



In Social Phobia, specific situations rather than interpersonal contact are avoided.



Panic Disorder with Agoraphobia also manifests avoidance but usually after the onset of panic attacks.

CONTD



Personality change due to GMC



Symptoms that may develop in association with chronic substance use (eg cocaine related disorder NOS)



Many individuals display avoidant personality traits.



Only when these traits are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress constitute AvPD.

DIFFERENTIATION

X Schizotypal and Schizoid

Presence of desire for social relations

Paranoid

avoidants do not confide in others because of fear being found inadequate, whereas paranoids fear malicious intent

Dependent Hypersensitivity to rejection, criticism, low self-esteem, feelings of inadequacy are also features of dependent PD.

avoidant patient avoids contact, dependent patient focuses on being cared for

T REATMENT 

Anxiety and hypersensitivity to rejection may improve with anxiolytic medication, beta-blockers, monoamine oxidase inhibitors, and antidepressant medication.



Medication should be combined with psychological treatment based on reinforcing assertiveness and self-esteem, and restructuring cognitive distortions concerning the self and others. Conscious and unconscious dependency needs should be addressed

D EPENDENT P ERSONALITY D ISORDER

HISTORY



belong to the abulic type of Kraepelin and of Schneider classifications and were considered as immature personalities.



recognized first in DSM-III



Hallmarks of Dependent PD are pervasive and excessive need to be taken care of leading to clinging behavior, submissiveness, fear of separation, and interpersonal dependency.



Lack of self-confidence was required in DSM-III, but was eliminated from recent classifications(not specific)

D IAGNOSTIC CRITERIA FOR 301.6 D EPENDENT PD



A pervasive & excessive need to be taken care of that leads to submissive, clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:



(1) has difficulty making everyday decisions without an excessive amount of advice and reassurance from others



(2) needs others to assume responsibility for most major areas of his or her life



(3) has difficulty expressing disagreement with others because of fear of loss of support or approval. Note: Do not include realistic fears of retribution.



(4) has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy)



(5) goes to excessive lengths to obtain nurturance and support from others, 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

CONTD



(7) urgently seeks another relationship as a source of care and support when a close relationship ends



(8) is unrealistically preoccupied with fears of being left to take care of himself or herself



Associated features Low self-esteem with self-doubt and self- defeating demeanor

D EPENDENT PERSONALITY DISORDER F60.7



at least 3 of the following:



(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 whom 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;

CONTD



(5)preoccupation with fears of being abandoned by a person with whom 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.



Associated features perceiving oneself as helpless, incompetent, and lacking stamina.



Includes: asthenic, inadequate, passive, and self-defeating personality (disorder)

A ETIOLOGY 

Dependent personality was the manifestation of fixation in the oral phase of psychosexual development(Freud).



Abraham believed that the disorder originated in an excess of oral gratification and protection.



More recent studies have ruled out these hypotheses and suggested that the excessive concern with oral satisfaction, passivity, self-doubt, and dependence are related to deprivation rather than overgratification in the oral phase.

C LINICAL

FEATURES



Passive, avoid responsibilities or decisions in major areas of their lives, (work, financial or interpersonal relationships)



Instead they get others, particularly family or partner, to decide for them or to provide continuous guidance.



Manifest self-doubt, pessimism, and need for affection, lack aggressiveness and appear helpless, rarely express needs or feelings, especially those that are sexual or aggressive



avoids jobs that demand taking responsibility and managing others, and becomes anxious when forced into such situations.



seek intensely for companionship and do not tolerate being alone.



do not initiate projects, but wait for others who, they believe, will do them better, but



function at an adequate level if in a close and protective relationship or to please whom they want to attach themselves



an excessive and unrealistic fear of abandonment is constant.



When an intimate relationship is terminated by separation or death, dependent individuals urgently seek another person who will provide the care and support they seek.



Thus they become rapidly and indiscriminately attached to other persons when left alone.



They belittle their capacities and successes and present themselves as inept.



accept unpleasant tasks, are self-sacrificing, and tolerate verbal, physical, or sexual abuse.



abusive relationships may be accepted as long as the attachment is preserved and is not excessively distorted.



They take criticism as a proof of their ineptness and confirmation of their lack of self-confidence.

C OMPLICATIONS 

Mood Disorders, Anxiety Disorders, Adjustment Disorder, Social Phobia. Low socioeconomic status, poor family and marital functioning.



Impairment



Frequently only mild; typically includes interpersonal relationships and occupational functioning if independence is required.

E PIDEMIOLOGY 

Reported in the DSM-IV-TR to be the most frequent of personality disorders.



prevalence of 0.7 per cent



Equally frequent in males and females



Chronic physical illness or Separation Anxiety Disorder may predispose for Dependent Personality Disorder.



Cultural factors may affect the reported prevalence, as passivity, politeness, and submission are normal in some societies.

C OMORBIDITY 

These patients are at increased risk for Major Depression, Anxiety Disorders, and Adjustment Disorder.



The most common co-occurring disorders are Histrionic, Avoidant, and Borderline.

C OURSE 

Dependent individuals are at increased risk of depressive, anxiety, and adjustment disorders, particularly in relation to loss of close relationships.



Dependent personality disorder may follow separation anxiety in childhood, or chronic physical illnesses in childhood requiring long periods of care and attention.

D IFFERENTIAL D IAGNOSIS 

Dependent disorder is distinguished from dependency seen in Mood Disorders, Panic Disorder, and Agoraphobia and as a result of a general medical condition , chronic substance use.



differentiated from normal dependent behaviours in specific life situations; eg. elderly people with chronic or debilitating disease may become dependent.

DIFFERENTIATION

X Borderline Both share an excessive fear of abandonment

reaction to abandonment with rage, emptiness, and demands, as opposed to appeasing and submissiveness seen in dependents

Histrionic Both adjust their conduct to please other people

obtain attention and care by seductive or manipulative behaviours, those with dependent PD wait passively for others to care for them

Avoidant

Dependents lack the sense of embarrassment and social shyness of the avoidant, and fear loneliness or abandonment.

T REATMENT 

Pharmacological treatment is indicated only when depressive or anxiety symptoms are present, especially when associated with separation or loss.



In psychotherapy, the therapist must avoid the development of excessively dependent attachments.



Self-confidence and self-esteem should be enhanced and the patient helped to enjoy the feeling of personal autonomy and independence.



Cognitive restructuring and social skills training are often useful in bringing these changes about.

O BSESSIVE -C OMPULSIVE ( ANANKASTIC ) P ERSONALITY D ISORDER



Hallmarks -pervasive, along with preoccupation with orderliness, perfectionism, and mental and interpersonal control at the expense of flexibility, openness, and efficiency

DSM IV TR O BSESSIVE -C OMPULSIVE P ERSONALITY D ISORDER 301.4



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 four (or more) of the following:



(1) is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost



(2) shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met)



(3) is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity)



(4) is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification)



(5) is unable to discard worn-out or worthless objects even when they have no sentimental value



(6) is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things



(7) adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes



(8) shows rigidity and stubbornness

ASSOCIATED FEATURES



Decision-making difficulties when no strict rules or established procedures dictate correct action



Anger and frustration when not able to maintain control of physical or interpersonal environment (anger typically not expressed directly)



Excessive attentiveness to his or her relative status in dominance–submission relationships



Controlled and restricted emotional expression, reserved personal style



Formal and serious quality of everyday relationships

ICD 10

CRITERIA FOR

ANANKASTIC DISORDER



at least three of the following:



(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 relationships;



(5)excessive pedantry and adherence to social conventions;



(6)rigidity and stubbornness;



(7)unreasonable insistence by the individual that others submit exactly to his or her way of doing things, or unreasonable reluctance to allow others to do things;



(8)intrusion of insistent and unwelcome thoughts or impulses.



Includes:



compulsive and obsessional personality (disorder)



obsessive-compulsive personality disorder



Excludes:



obsessive-compulsive disorder



Biological factors and learning seem to be involved in the aetiology of OCPD,may be partly inherited.



Early psychodynamic theories linked obsessive personality to the anal phase of psychosexual development between the ages of 2 and 4, when libidinal drives come into conflict with parental attempts to socialize the child, especially in sphincter control and toilet training.



Later psychoanalytic theory emphasized earlier manifestations of the child's autonomy versus parental wishes.



The expression of drives and emotions, including anger, is shaped by parental responses and may evoke shame and criticism



As children, obsessional patients were often praised for what they did as opposed to who they were.



The child could avoid criticism by focusing on tasks and displacing anger.



By adopting moralistic attitudes towards anger, the child gained affection and attention from the parents.



This dynamic sequence is reinforced in societies where individual emotions are subordinated to the group, and open expression of emotions is discouraged



Predisposing Factors



It has been repeatedly demonstrated that OCPD and OCD frequently coexist.



Obsessions and compulsions have been repeatedly linked to high central serotonergic function, which is associated with anxiety in general, supporting the hypothesis that obsessions and compulsions represent psychological and behavioral mechanisms reflecting underlying anxiety.



More recent investigations(104) indicate that most obsessive–compulsive disorder patients do not have a comorbid obsessive–compulsive personality disorder.

C LINICAL

FEATURES



Consistently orderliness



preoccupied with details, and pays attention to rules, procedures, schedules, and punctuality



repeat actions and check for mistakes, despite the inconvenience and annoyance that result from this behaviour



As a consequence, their conduct is frequently inefficient (as striving for perfection and order is time consuming)



focus on work and productivity, difficult for them to take vacations or even to have free time



do not enjoy leisure activity, consider a waste of time



take work home to alleviate their anxiety



Hobbies and leisure pursuits become formally organized activities



Stubbornness is another characteristic



need things to be done in their way, and realistic arguments do not usually make them change their insistence



often believe that no one can do the tasks as perfectly as they can



generally insist in doing everything themselves and are unable to delegate, which increases their inefficiency at work



Paradoxically, their stubbornness is associated with doubt



Indecisiveness is a constant characteristic unless they have structured guidelines



fear making mistakes or misjudgements,



inflexible about matters of morality, ethics, or values



dislike spending , money should be saved in case of future difficulties



hoard objects, believing that they might be useful some day



humourless and lack spontaneity of emotional expression



do not express anger directly but by indirect aggressive acts



attitude of dominance–submission toward authority figures



excessively submissive to a person in authority whom they respect, but obstructive with an authority figure whom they do not respect



affect of the obsessive person is controlled and stilted. It is not flat or blunted, but constricted



They do not laugh or cry, and feel uncomfortable with people who express their feelings



In summary, obsessive personalities love order, neatness, and sameness, and hates novelty, spontaneity, and change,



need control, security, and certainty, and avoid creativity, art, and excitement.



They mitigate anxiety by following strict rules and repress emotional expression by avoiding spontaneity. They fear their inner fragile and aggressive emotional world.

C OMPLICATIONS 

Distress and difficulties when confronted with new situations that require flexibility and compromise;



myocardial infarction (secondary to features typical of type A personalities, such as time urgency, hostility, and competitiveness).

E PIDEMIOLOGY 

The DSM-IV reports prevalence rates of 1 percent in the general population and 3 to 10 percent for psychiatric outpatients.



Sex Ratio



According to DSM-IV-TR, this disorder is twice as common in males than in females.



Familial Pattern and Genetics



Some studies have demonstrated familial aggregation of this disorder.

COURSE



present in early adulthood and tends to be persistent and constant



some adolescents with marked obsessive traits become warm, loving, and tender adults.



intense obsessional traits in adolescence are occasionally a premorbid stage of schizophrenia (‘pseudoneurotic schizophrenia').



Hypochondriacal syndromes are commonly found in obsessive individuals when they lose control of situations.



Late-onset depression is a common occurrence in obsessive–compulsive personalities

C OMORBIDITY 

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.

D IFFERENTIAL D IAGNOSIS 

OCPD is distinguished from OCD based on true obsessions and compulsions in the latter.



The latter diagnosis is made when occupational and personal functioning is severely impaired as a consequence of doubt, indecisiveness, hoarding, or any other obsessive behaviour.

ocpd

ocd

Often ego syntonic—marked by the person's acceptance

Often egodystonic ( incompatible with the sufferer's self-concept, cause much distress)

readily explain why their actions are rational

tend to derive pleasure from their obsessions or compulsions

often aware that their behavior is not rational and are unhappy about their obsessions but nevertheless feel compelled by them OCD are ridden with anxiety

DIFFERENTIATION

narcissistic individuals tend to believe X Narcissistic(sense of grandiosity, exhibitionism) that they have achieved perfection, Perfectionism may be present

while obsessive individuals tend to be highly critical of their own achievements

Schizoid Social detachment, lack of empathy and warmth may suggest schizoid personality disorder.

However, obsessive individuals constrain their emotional expression to keep control of a situation, while schizoids lack the fundamental capacity for affective display or intimacy.

Antisocial

material goals in antisocial behavior and criminality as opposed to the hypermorality of obsessive personalities

TREATMENT 

Pharmacological treatment may be tried in patients with anxiety and distress due to intense doubts, indecisiveness, and scruples.



Benzodiazepines may alleviate tension in these cases.



Antidepressants with a serotonergic profile sometimes improve mood and global functioning.



Psychological treatment, focusing on perfectionism, rigidity, scrupulousness, and intolerance of failure, is the main therapeutic approach.



Repressed aggression, guilt, and dependency needs should be addressed using a psychodynamic approach.

D SM

V



The primary changes include an incorporation of a hybrid dimensional-categorical framework including:



Categorical Types; Dimensional Traits; and Dimensional Functioning.



Types The DSM-5 reduces the 10 specific personality disorders of the DSM-4 to six specific personality disorder types, including:



Antisocial; Avoidant; Borderline; Narcissistic; Obsessive/Compulsive; and Schizotypal.



introduction of dimensionally measured personalitydisordered traits, from normality to pathology



levels of personality functioning scale from mild to extreme.

M NEMONICS 

AvPD



Avoids occupational activities Views self as socially inept Occupied with being criticized or rejected Inhibited in new interpersonal situations Declines to get involved with people Embarrassed by engaging in new activities Refrains from intimate relationships

D EPENDENT PD



D – Difficulty making everyday decisions



E – Excessive lengths to obtain nurturance and support from others



P – Preoccupied with fears of being left to take care of self



E – Exaggerated fears of being unable to care for himself or herself



N – Needs others to assume responsibility for his or her life



D – Difficulty expressing disagreement with others



E – End of a close relationship is the beginning of another relationship



N – Noticeable difficulties in initiating projects or doing things on his or her own



T – “Take care of me” is his or her motto

SCALES



Personality diagnostic questionnaire 4+(1994)



SCID II personality questionnaire(1997)



Wisconsin personality disorders inventory



MMPI-2 and PAI



Million clinical multiaxial Inventory



NEO personality inventory

THANK U