The DSM-5 organizes 10 personality disorders into 3 groups, or clusters, based on shared key features. Cluster C Personality disorders includes 3 disorders sharing anxious and fearful features. Avoidant, Dependent, and Obsessive-Compulsive.

1. CLUSTER C PERSONALITY
DISORDERS
Presenter- Dr. Subhendu Sekhar Dhar

2. OUTLINE
• INTRODUCTION
• DEFINITION OF PERSONALITY DISORDER
• CLUSTERS
• AVOIDANT PERSONALITY DISORDER
• DEPENDENT PERSONALITY DISORDER
• OBSESSIVE-COMPULSIVE PERSONALITY DISORDER
• SUMMARY
• REFERENCES

3. INTRODUCTION
PERSONALITY
• The understanding of personality and its disorders is what distinguishes
psychiatry fundamentally from all other branches of medicine.
• A person is a self-aware human being, not a machine-like object that lacks self-
awareness.
• Personality refers to all the ways in which someone shapes and adapts in a
unique way to ever-changing internal and external environments.

4. DEFINITION OF PERSONALITY DISORDER
• Severe disturbance in the characterological constitution and behavioural
tendencies of the individual, usually involving several areas of the personality,
and nearly always associated with considerable personal and social disruption.
(ICD-10)
• Enduring pattern of inner experience and behaviour that deviates significantly
from the expectation of the individual's cultural standards; is rigidly pervasive;
has an onset in adolescence or early adulthood; is stable over time, and leads to
unhappiness or impairment; and manifests in at least two of the following four
areas: Cognition, Affectivity, Interpersonal function and Impulse control.
(DSM-5)

5. CLUSTERS
• The DSM-5 organizes 10 personality disorders into 3 groups, or clusters, based
on shared key features.
• Cluster A includes 3 disorders with odd, aloof features.
Paranoid, Schizoid, and Schizotypal.
• Cluster B includes 4 disorders with dramatic, impulsive, and erratic features.
Borderline, Antisocial, Narcissistic, and Histrionic.
• Cluster C includes 3 disorders sharing anxious and fearful features.
Avoidant, Dependent, and Obsessive-Compulsive.

6. AVOIDANT (ANXIOUS) PERSONALITY DISORDER
• The patient with avoidant personality is essentially a shy, inhibited person who
has feelings of inadequacy and low self-esteem.
• These patients are hypersensitive to perceived
criticism, but have the capacity to develop
appropriate relationships if they feel safe and
accepted.
• They may lead socially withdrawn lives.
• These people are commonly described as
having an inferiority complex.

7. EPIDEMIOLOGY
• Prevalence rates of 2 - 3 % in the general population.
• 10 % for psychiatric outpatients.
• This disorder is equally frequent in males and females.
• Infants classified as having a timid temperament is more susceptible to the
disorder.

8. DIAGNOSTIC CRITERIA (DSM-5)
• A pervasive pattern of Social inhibition, Feelings of inadequacy, Extreme sensitivity to
negative evaluation, beginning by early childhood.
• Requires at least 4:
1. Avoids occupational activities that involve significant
social contact, due to fears of disapproval or rejection.
5. Inhibited in new social situations because of feelings
of inadequacy.
2. Unwilling to deal with people unless sure of being
liked.
6.Views themselves as socially inept, personally
unappealing, or inferior to others.
3. Restraint within intimate relationships due to fear of
being shamed or ridiculed.
7. Unusually reluctant to take risks or to engage in new
activities because they may prove embarrassing.
4. Preoccupied with being criticized or rejected in social
situations.

9. DIAGNOSTIC CRITERIA (ICD-10)
• Avoidant PD characterized by at least 3 of the following:
a. persistent and pervasive feelings of tension and apprehension;
b. belief that one is socially inept, personally unappealing, or inferior to others;
c. excessive preoccupation with being criticized or rejected in social situations;
d. unwillingness to become involved with people unless certain of being liked;
e. restrictions in lifestyle because of need to have physical security;
f. 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.

10. AVOIDANT PERSONALITY DISORDER
COMPLICATIONS: Social Phobia.
COMORBIDITY: These patients are at increased risk for Mood and Anxiety
Disorders (especially Social Phobia, generalized type). About 25-50% have Panic
Disorder, 10-25% have Generalized Anxiety Disorder, 20-25% have an Eating
Disorder, and more than 33% have Body Dysmorphic Disorder (Alden LE et al.
2002).The most common co-occurring disorders are Schizotypal, Schizoid,
Paranoid, Dependent, and Borderline.
IMPAIRMENT: Can be severe; typically includes occupational and social
difficulties.

11. DIFFERENTIAL DIAGNOSIS
Social Phobia Very difficult to distinguish. In Social Phobia, specific situations rather
than interpersonal contact are avoided.
Panic Disorder with
Agoraphobia
Manifests avoidance usually after the onset of panic attacks.
Schizotypal and
Schizoid PD
Social isolation of avoidant personalities is accompanied by the desire for
social relations, which is not observed in Schizoid and Schizotypal PD
Paranoid PD Includes guarded attitude, preoccupation with hidden meanings, and
conspiratorial explanations of benign events
Dependent PD Is focused on being taken care of rather than on the fear of negative
evaluation

12. COURSE & PROGNOSIS
• Many persons with Avoidant PD are able to function in a protected
environment.
• Some live their lives surrounded only by family members.
• If their support system fails, they are subject to depression, anxiety & anger.
• Phobic avoidance is common.
• Pts. with Avoidant PD give histories of social phobia or incur social phobia in the
course of their illness.
• Avoidant PD have chronic and persistent course.

13. TREATMENT
PSYCHOTHERAPY: There have actually been a couple of studies that have
examined the effects of psychotherapy for Avoidant PD. Social SkillsTraining &
ExposureTherapy are helpful.
One found that 20 sessions of Cognitive BehavioralTherapy (CBT) brought some
improvement in symptoms, and was superior to 20 sessions of Psychodynamic
Psychotherapy (PP) (Emmelkamp PM et al. 2006).
Another study found that 40 sessions of CBT was equally effective to 40 sessions
of PP. (Svartberg M et al. 2004).
PHARMACOTHERAPY: Used to manage anxiety & depression associated with
disorder. Some pts. are helped by Beta adrenergic receptor antagonists (Atenolol)
to manage autonomic nervous system hyperactivity.

14. DEPENDENT PERSONALITY DISORDER
• Persons with Dependent PD subordinate their own needs to those of others.
• Get others to assume responsibility for major areas of their lives.
• Has difficulty making everyday decisions without
an excessive amount of advice and reassurance
from others.
• Lack self-confidence.
• Experience intense discomfort when
alone for more than a brief period.

15. EPIDEMIOLOGY
• Prevalence rates of 0.6 – 3.7% in the general population.
• Female > Male.
• More common in younger children than in older ones.
• Person with chronic physical illness in childhood may be most susceptible to the
disorder.

16. DIAGNOSTIC CRITERIA (DSM-5)
• A pervasive and excessive need to be taken care of that leads to submissive and clinging
behavior and fears of separation, beginning by early adulthood and present in a variety of
contexts, as indicated by 5 or more of the following:
1. has difficulty making everyday decisions without an
excessive amount of advice and reassurance from
others
5. goes to excessive lengths to obtain nurturance and
support from others, to the point of volunteering to do
things that are unpleasant
2. needs others to assume responsibility for most major
areas of his or her life
6. feels uncomfortable or helpless when alone because
of exaggerated fears of being unable to care for himself
or herself
3. has difficulty expressing disagreement with others
because of fear of loss of support or approval.
Note: Do not include realistic fears of retribution.
7. urgently seeks another relationship as a source of care
and support when a close relationship ends
4. has difficulty initiating projects or doing things on his
or her own
8. is unrealistically preoccupied with fears of being left
to take care of himself or herself

17. DIAGNOSTIC CRITERIA (ICD-10)
• Dependent PD characterized by at least 3 of the following:
a. encouraging or allowing others to make most of one’s important life decisions;
b. subordination of one’s own needs to those of others on whom one is dependent,
and undue compliance with their wishes;
c. unwillingness to make even reasonable demands on the people one depends on;
d. feeling uncomfortable or helpless when alone, because of exaggerated fears of
inability to care for oneself;
e. preoccupation with fears of being abandoned by a person with whom one has a
close relationship, and of being left to care for oneself;
f. limited capacity to make everyday decisions without an excessive amount of
advice and reassurance from others.
• Associated features may include perceiving oneself as helpless, incompetent,
and lacking stamina.

18. DEPENDENT PERSONALITY DISORDER
COMPLICATIONS: Mood Disorders, Anxiety Disorders, Adjustment Disorder,
Social Phobia. Low socioeconomic status, poor family and marital functioning.
COMORBIDITY: Eating Disorders, Anxiety Disorders, Somatoform Disorders, and
other Personality Disorders (Histrionic, Avoidant, and Borderline). About 30% of
these individuals can be diagnosed with Depression, over 10% with Bipolar
Disorder, and about 7% have Dysthymia (Overholser JC 1996).
IMPAIRMENT: Frequently only mild; typically includes interpersonal relationships
and occupational functioning if independence is required.

19. DIFFERENTIAL DIAGNOSIS
Mood/Anxiety
Disorders/General
medical conditions
These dependency behaviors would be expected to stop once the
underlying illness resolves.
Borderline PD Usually have a strong fear of being abandoned, but will tend to react
with feelings of rage and emotional emptiness and demands as
opposed to increasing appeasement. Submissiveness seen with
dependent personalities
Histrionic PD Tend to gain attention from others through dramatic and flamboyant
behavior, as opposed to people with Dependent Personality Disorder,
who will be more self-effacing and docile.
Avoidant PD Social isolation because of the fear of negative evaluation as opposed
to clinging and submissive behavior of dependent personalities

20. COURSE & PROGNOSIS
• Little is known about the course of Dependent PD.
• Occupational functioning tends to be impaired because the person can’t act
independently & without close supervision.
• Social relationships are limited to those on whom they can depend.
• Risk of MDD if they lose the person on whom they depend.
• With treatment the prognosis is favourable.

21. TREATMENT
PSYCHOTHERAPY: Insight-oriented therapies enable patients to understand the
antecedents of their behaviour, become more independent, assertive & self-
reliant.
Behavioral therapy, Assertiveness training, Family therapy & Group therapy have
been used with successful outcomes in many cases.
PHARMACOTHERAPY: Medications would not be expected to help very much for
the core symptoms of Dependent Personality Disorder, but will often be used to
treat any associated psychiatric conditions.

22. OBSESSIVE-COMPULSIVE PERSONALITY DISORDER
Characterized by a general pattern of concern with
• orderliness,
• perfectionism,
• excessive attention to details,
• mental and interpersonal control,
• a need for control over one's environment,
• at the expense of flexibility, openness to
experience and efficiency.

23. EPIDEMIOLOGY
• Prevalence rates of 2- 8% in the general population.
• 8–9% of psychiatric outpatients.
• Female: Male = 1:2
• Most often in oldest siblings.

24. DIAGNOSTIC CRITERIA (DSM-5)
• 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 4 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
5. is unable to discard worn-out or worthless objects even
when they have no sentimental value
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)
6. is reluctant to delegate tasks or to work with others
unless they submit to exactly his or her way of doing
things
3. is excessively devoted to work and productivity to the exclusion
of leisure activities and friendships (not accounted for by obvious
economic necessity)
7. adopts a miserly spending style toward both self and
others; money is viewed as something to be hoarded for
future catastrophes
4. is overconscientious, scrupulous, and inflexible about matters
of morality, ethics, or values (not accounted for by cultural or
religious identification)
8. shows rigidity and stubbornness

25. DIAGNOSTIC CRITERIA (ICD-10)
• Personality disorder characterized by at least 3 of the following:
a. feelings of excessive doubt and caution;
b. preoccupation with details, rules, lists, order, organization or schedule;
c. perfectionism that interferes with task completion;
d. excessive conscientiousness, scrupulousness, and undue preoccupation with
productivity to the exclusion of pleasure and interpersonal relationships;
e. excessive pedantry and adherence to social conventions;
f. rigidity and stubbornness;
g. unreasonable insistence by the patient that others submit to exactly his or her way
of doing things, or unreasonable reluctance to allow others to do things;
h. intrusion of insistent and unwelcome thoughts or impulses.

26. OBSESSIVE-COMPULSIVE PERSONALITY DISORDER
COMPLICATIONS: Distress and difficulties when confronted with new situations
that require flexibility and compromise.
COMORBIDITY: 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.

27. DIFFERENTIAL DIAGNOSIS
• It has been found that Obsessive-Compulsive Personality Disorder and
Obsessive-Compulsive Disorder frequently coexist.
OCD OCPD
OCD is defined by the presence of true obsessions
and/or compulsions.
with OCPD, the behaviors are not directed by
thoughts that are unable to control or irrational
behaviors that repeat over and over again, often with
no apparent aim.
Ego dystonic Ego syntonic
Symptoms of OCD tend to fluctuate in association
with the underlying anxiety
In OCPD, the behaviors tend to be persistent and
unchanging over the long term
Often seek professional help to overcome the
irrational nature of their behavior and the persistent
state of anxiety they live under.
Usually not seek help because they don't see that
anything they are doing is particularly abnormal or
irrational.

28. DIFFERENTIAL DIAGNOSIS
Schizoid PD Lack of capacity for intimacy and social isolation secondary to
emotional detachment, as opposed to devotion to work and
discomfort with emotions
Antisocial PD Material goals in antisocial behavior and criminality as opposed
to the hypermorality of obsessive personalities
Avoidant PD Isolation due to fears of disapproval or rejection, feelings of
inadequacy. In OCPD isolation results from giving priority to
work and productivity rather than relationships

29. COURSE AND PROGNOSIS
• Course is variable & unpredictable.
• Some adolescents with OCPD evolve into warm, open & loving adults.
• The disorder can be the harbinger of Schizophrenia or MDD.
• Individuals with OCPD often experience a moderate level of professional success
but they are vulnerable to unexpected changes & their personal lives may
remain barren.
• Late onset Depressive disorder are common.

30. TREATMENT
PSYCHOTHERAPY: Insight-oriented psychodynamic techniques and cognitive
behavioral therapy are helpful.
Specific breathing and relaxation techniques can help decrease the sense of stress
and urgency.
PHARMACOTHERAPY: SSRIs appear to help the OCPD patients with their
rigidity and compulsiveness.

31. CLUSTER C PERSONALITY DISORDERS:
MANIFESTATIONS AND MANAGEMENT STRATEGIES
Personality
Disorder
Prominent features
of disorder
Experience of
illness
Problematic behaviors in
medical setting
Management strategies
Avoidant Social inhibition due
to fears of rejection or
humiliation
Heightened
sense of
inadequacy, low
self-esteem
Withholds information,
avoids questioning or
disagreeing with physician
Provide reassurance, validate
concerns, encourage reporting of
symptoms and concerns.
Dependent Excessive need to be
taken care of,
submissive and
clinging behavior
Fear of
abandonment,
helplessness
Urgent demands for
attention, prolongation of
illness behavior to obtain
attention and care
Provide reassurance, schedule
regular check-ups, set realistic limits
on availability, enlist others to
support patient, avoid rejection of
patient.
Obsessive-
Compulsive
Preoccupation with
orderliness,
perfection, control
Fear of losing
control of bodily
functions and
emotions
Fear of relinquishing
control, excessive
questioning and attention
to details, anger about
disruption of routines
Complete thorough history and
examinations, provide thorough
explanations, encourage patient
participation in treatment.

32. REFERENCES
• Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 10th ed.
• Kaplan & Sadock’s Synopsis of Psychiatry
• DSM-5
• ICD-10
• Emmelkamp PM et al. Comparison of brief dynamic and cognitive-behavioural therapies in
avoidant personality disorder. British Journal of Psychiatry 2006; 189: 60-4.
• Alden LE et al. Avoidant personality disorder: current status and future directions. Journal of
Personality Disorders 2002; 16(1): 1-29.
• Svartberg M et al. Randomized, controlled trial of the effectiveness of short-term dynamic
psychotherapy and cognitive therapy for cluster C personality disorders. American Journal of
Psychiatry 2004; 161(5): 810-7.
• Overholser JC. Journal of Nervous and Mental Disease 1996; 184(1): 8-16.
• Google images.

33. THANKYOU