Approach to avoidant, dependent, and obsessive-compulsive (cluster C) personality disorders: Clinical sciences

Chapters:

Watch video only

Introduction 0:00–1:00

Personality disorders are characterized by an enduring and pervasive pattern of perceiving and relating to oneself, others, and the world in atypical, and often detrimental, ways.
Unlike individuals with other psychiatric conditions, those with personality disorders have ego-syntonic thoughts and behaviors, meaning they do not perceive their condition as problematic.
Consequently, personality disorders typically do not cause direct distress to the individual but can lead to significant interpersonal and occupational difficulties.
There are ten personality disorders defined in the Diagnostic and Statistical Manual of Mental Disorders fifth edition, or DSM-5 for short; and these are divided into clusters A, B, and C.
Cluster C personality disorders include avoidant personality disorder, obsessive-compulsive personality disorder, and dependent personality disorder.
Now, when a patient presents with a chief concern suggesting a personality disorder, first obtain a focused history and physical exam.

H&P 1:00–1:58

Symptoms might include significant interpersonal or occupational difficulties, And patterns of hyper-dependence on or hyper-independence from others.
The patient could also have a tendency to blame others for their own feelings and behaviors. Additionally, you might find frequent or extreme mood swings, angry outbursts, and attention seeking behaviors.
Keep in mind many of these traits might be reported by family, teachers, or friends. The physical exam is often unremarkable, but you might notice extremes of affect, ranging from flat to exaggerated facial expressions during your interaction with the patient.
With these findings, consider a personality disorder. Your next step is to assess your patient for a general personality disorder using the DSM-5 criteria.

Personality disorder 1:58–2:52

All personality disorders are characterized by an enduring pattern of thinking, feeling, and behaving in culturally atypical ways; and these traits are inflexible and maladaptive in multiple settings.
The onset of this pattern must be during adolescence or early adulthood, although traits might be recognized at much younger ages.
Additionally, to be considered disordered, the patient’s symptoms must cause clinically significant distress or impairment, and they cannot be explained by another mental or medical condition, nor by any substance effects.
If these criteria are met, diagnose a general personality disorder. Then, assess for key personality traits to determine the cluster type.

Assess key traits/Cluster C 2:52–3:51

Here’s a high yield fact! There are 3 major clusters of personality disorders: A, B, and C.
You can remember them by the group name. Cluster A disorders include paranoid which is accusatory; schizoid which is aloof; and schizotypal which can be described as atypical.
With B disorders, think narcissistic is the best; histrionic boast; antisocial break laws; and borderline... well there is already a right B there.
Lastly, for cluster C, avoidant can be described as cowardly; dependent as clingy; while obsessive-compulsive doesn’t need really additional descriptions.
Now, if your patient is predominantly worried, anxious, or fearful, think of cluster C personality disorders, and then assess for a pattern of social avoidance.
If present, consider avoidant personality disorder. These individuals often desire relationships, but their fear of rejection and disapproval causes them to withdraw socially.

Avoidant personality disorder 3:51–6:01

Your patient may avoid activities requiring significant interpersonal contact, and they might be reluctant to try new activities or take personal risks.
They are often inhibited in new social situations due to feelings of inadequacy, and they tend to avoid becoming involved with others, unless social acceptance is guaranteed.
Affected individuals tend to be reserved in close relationships due to a fear of shame or ridicule, and they frequently experience feelings of social ineptitude and inferiority.
Their low self-confidence results in an intense fear of rejection, criticism, and embarrassment. If history reveals several of these features, assess the DSM-5 diagnostic criteria for AVPD.
Patients must demonstrate at least 4 of the behavior patterns described from the history, with an enduring pattern of social avoidance and intense fear of disapproval, as well as an onset by early adulthood.
If these criteria are met, diagnose avoidant personality disorder. Here’s a clinical pearl!
Individuals with AVPD and social anxiety disorder display similar social fears and avoidance behaviors, but their symptoms differ in scope, severity, and underlying beliefs.
AVPD is characterized by a deep sense of inferiority and pervasive fear of rejection, leading to avoidance of almost all social interactions.
On the other hand, individuals with social anxiety disorder feel inadequacy that is transient and limited to specific social situations, especially those where formal observation and evaluation are anticipated.
In most cases, symptoms of AVPD are more pervasive, severe, and socially disruptive than those seen in social anxiety disorder.
Let’s switch gears and talk about patients without a pattern of social avoidance. In this case, your next step is to assess for perfectionism.

Obsessive-compulsive personality disorder 6:01–8:48

If present, consider obsessive-compulsive personality disorder, or OCPD. These individuals typically exhibit a high level of perfectionism that interferes with effective task completion.
They spend unreasonable amounts of time on tasks and become preoccupied with details, lists, and rules until their high standards are met.
Additionally, they are reluctant to share or delegate tasks, and when teamwork is required, they tend to micromanage others to ensure tasks are done the right way.
Because of this, others often see them as rigid, stubborn, and excessively focused on work and productivity, at the expense of leisure activities.
Even outside of work, they will often follow rigid moral principles, and believe there is a right way to do everything, so any deviation is judged harshly.
Many adopt a miserly spending style and are unable to dispose of worn-out or worthless possessions that lack sentimental value.
If history reveals several of these features, assess the diagnostic criteria for OCPD using the DSM-5. Patients must demonstrate at least 4 of the behavior patterns described from the history, as well as an enduring preoccupation with perfection, order, and control, with onset by early adulthood.
If these criteria are met, diagnose obsessive-compulsive personality disorder. Here’s another clinical pearl!
OCPD and obsessive-compulsive disorder, or OCD, share some common features related to obsessive thoughts and compulsive behaviors; but it's important to note that only OCD involves true obsessions and compulsions.
Individuals with OCD experience repetitive, unwanted thoughts that are irrational and distressing, yet impossible to ignore.
They also perform compulsions which are repetitive physical or mental acts that attempt to reduce the distress caused by an obsession.
Individuals with OCD have thoughts and behaviors that are disruptive, distressing, and time-consuming. They provide no personal benefit; and some even cause direct harm.
In contrast, OCPD is typically ego-syntonic, and some individuals with this condition even gain personal and professional benefits from their organizational skills, attention to detail, and commitment to excellence.
Let's move on and discuss patients who don’t have symptoms of perfectionism. Here, you should dig deeper into the history and assess your patient’s interpersonal relationships, to look for patterns that suggest dependent personality disorder, or DPD.

Dependent personality disorder 8:48–10:19

Individuals with DPD express a strong need for someone else to take responsibility for them. They often experience intense fear of separation and being left alone to care for themselves, since they tend to feel uncomfortable and helpless when alone.
Because they lack self-confidence, these individuals have difficulty making decisions without advice and reassurance. They may volunteer to do things that are unpleasant, to gain the approval or support of others.
As well, they often have difficulty expressing disagreement, because they fear losing approval. Their low self-confidence also leads to difficulty initiating projects.
Finally many desperately seek another relationship for a new source of support after a close relationship ends. If history reveals several of these features, consider DPD, and assess the DSM-5 criteria for DPD.
Patients must demonstrate 5 or more behavior patterns from the history, with a pervasive and excessive dependence on others, as well as an onset by early adulthood.
If these criteria are met, diagnose dependent personality disorder. Alright, as a quick recap… Individuals with personality disorders have an enduring pattern of perceiving and relating to themselves, others, and the world in atypical, and often detrimental, ways.

Review 10:19–11:03

When assessing a patient for a cluster C personality disorder, look for key historical features, and evaluate according to the DSM-5 criteria.
When a patient exhibits social avoidance, think avoidant personality disorder, defined by an enduring pattern of social avoidance and intense fear of disapproval.
On the other hand, if a patient displays a pattern of perfectionism, think obsessive-compulsive personality disorder, characterized by a preoccupation with perfection, order, and control.
Finally, if your patient is excessively dependent and needs others to take responsibility for them,