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

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. 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.

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.

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. 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. 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.