Cluster C

Personality Disorders
Group 3
Psychopathology - I

Group members:
Klirdap Tabitha Ingty John
Lalchhanhimi Bawlte
Lalhriatpuii
Lalnunpuia Hlawndo
Lalruatkima
Lalthazuali Hnamte
Lalvenhimi
INTRODUCTION
What are personality disorders?

These types of condition comprise deeply ingrained and enduring behaviour patterns,
manifesting themselves as inflexible responses to a broad range of personal and social situations.
They represent either extreme or significant deviations from the way the average individual in a
given culture perceives, thinks, feels, and particularly relates to others. Such behaviour patterns
tend to be stable and to encompass multiple domains of behaviour and psychological
functioning.

They are developmental conditions, which appear in childhood or adolescence and continue into
adulthood. They are not secondary to another mental disorder or brain disease, although they
may precede and coexist with other disorders.6

Cluster C Personality Disorders

These disorders often appear anxious or fearful.

This category includes :

•Anankastic Personality Disorder or Obsessive Compulsive Personality Disorder.

•Anxious [Avoidant] Personality Disorder

•Dependent Personality Disorder

ANANKASTIC PERSONALITY DISORDER OR OBSESSIVE-COMPULSIVE

PERSONALITY DISORDER

Diagnostic Criteria ( ICD-10 )

F60.5 – Anankastic Personality Disorder

(a) feelings of excessive doubt and caution;

(b) preoccupation with details, rules, lists, order, organization or schedule;

(c) perfectionism that interferes with task completion;

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(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.

Includes: compulsive and obsessional personality (disorder) obsessive-compulsive personality

disorder

Excludes: obsessive-compulsive disorder (F42.-)

Diagnostic Criteria ( DSM-V )

301.4 – Obsessive Compulsive Personality Disorder

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).

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Clinical Presentation

• The main features include punctuality, neatness, difficulty with uncertainty, and a
great need to be in control.

• They insist that rules be followed rigidly and cannot tolerate what they consider
infractions; they lack flexibility and are intolerant.

• They have limited interpersonal skills. Formal and serious and often lack a sense
of humor, they alienate persons, are unable to compromise, and insist that others
submit to their needs.

• They fear making mistakes, they are indecisive, and ruminate about making
decisions.

• Anything that threatens to upset their perceived stability or the routine of their
lives can precipitate much anxiety otherwise bound up in the rituals that they
impose on their lives and try to impose on others.2

Case Study

Mark is a 42 year old, single male who lives with his parents. He has been unemployed for some
time because he has had difficulty maintaining employment. Most recently, he was not able to
meet production demands at his factory job because he got consumed with making each package
perfect before moving on to the next package. One weekend, when his family planned to visit the
grandparents, Mark started packing on Wednesday afternoon but did not finish packing until
Saturday, when it was too late to go. Mark's employment and personal relationships are impacted
by his rigidity and extreme attention to detail. Mark was diagnosed with OCPD. In therapy, Mark
was very punctual in treatment and never missed a session; he talked freely and in great detail.
The initial part of therapy mainly dealt with family relationships. When the time came to have
the sessions, he would often continue talking and delaying even when the therapist was standing
at the door.

Recent research

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Recent studies on OCPD have analysed its relationship with many variables like perfectionism,
coping, social interaction anxiety and even its neural connections. In a study that analysed the
impact of OCPD on perfectionism (Redden, Mueller & Cougle,2023), those with OCPD had
higher levels of general and specific domains of perfectionism as well as higher levels of social
anxiety. In another study, the researchers attempted to add social interaction anxiety and
maladaptive coping to the criteria of diagnosis for which they reported to have good validity for
anxiousness and workaholism (Seretis, Hart & Maguire,2023). Another study looked into the
neural mechanisms of decision-making under ambiguous circumstances and compared them
between those with OCD and OCPD (Luo, Chen, Li, Dong, Zhou, Qui & Wang, 2020). Some of
the results included that OCD subjects chose more disadvantageous options and were more
‘short-sighted’ in comparison to those with OCPD in a gambling simulation despite them
showing similar neural mechanisms in other ambiguous situations. They also used the Hamilton
Anxiety Rating Scale and Hamilton Depression Rating Scale to verify that OCPD was better
associated with behavioural performance compared to OCD patients. In a study that analysed the
brain activity in those with OCPD, they used functional magnetic resonance imaging and
showed that there were significant differences in regional Amplitudes of Low Frequency
Fluctuation (ALFF) between those with OCPD and ‘normal’ individuals (Lei, Huang, Li, Liu,
Fan, Zhang, Rao, 2020). Those with OCPD had increased ALFF in the bilateral caudate, left
precuneus, left insula and left medial superior frontal gyrus and decreased ALFF in the left
precuneus instead. This showed that those with OCPD exhibited spontaneous neural activity in
brain regions related to cognitive inflexibility, excessive self-control, lower empathy and visual
attention bias.

ANXIOUS [AVOIDANT] PERSONALITY DISORDER

Diagnostic criteria ( ICD -10 )

F60.6 – Anxious [Avoidant] Personality Disorder

(a) persistent and pervasive feelings of tension and apprehension;

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

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(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.

Diagnostic criteria ( DSM -V )

301.82 – Avoidant Personality Disorder

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.

Clinical Presentation

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 • They are shy, tense and easily embarrassed. As a result they are isolated and
lonely, yet have an overwhelming need to be accepted, while also being unsure of
their self-worth.

• Compensate by engaging in solitary intellectual pursuits.

• Hypersensitivity to rejection by others is the central clinical feature of avoidant

personality disorder, and patients’ main personality trait is timidity.

• They desire the warmth and security of human companionship but justify their
avoidance of relationships by their alleged fear of rejection.

• They are apt to misinterpret other persons’ comments as derogatory or ridiculing.

• These persons are generally unwilling to enter relationships unless they are given
an unusually strong guarantee of uncritical acceptance.

• Anxious personality disorder is more generalised, with fear extending to multiple

areas of social encounter, whereas social anxiety disorder is more limited to one
of a few areas.2

Case Study

The patient was 35-year-old, unmarried data technician William, referred to a specialized
treatment program for personality disorders from an outpatient drug addiction service. His
personality pathology was considered more devastating than his substance abuse. Presenting
complaints included low self-esteem, loneliness, a sense of emptiness, suicidal ideation, social
isolation, substance abuse, and general dissatisfaction with life. Present complaints had been
chronic in nature, dating back to childhood.

William recalled having daily suicidal thoughts for several years in his early youth. His avoidant
behavior was more prominent than his level of experienced anxiety. William’s most prominent
feature was a pervasive fear of being ridiculed when interacting with others, and he was
diagnosed with avoidant personality disorder.

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In a group-based treatment program lasting for 20 weeks, he was a regular, but somewhat
detached participant. The therapists encountered a series of problems related to passivity: he
postponed most of his obligations, resisted sorting out practical affairs, did not pay his bills, and
avoided contacting people who could be helpful.

Recent Research
Avoidant personality disorder (AVPD) is a relatively common disorder that is associated with
significant distress, impairment, and disability. It is a chronic disorder with an early age at onset
and a lifelong impact. Yet it is underrecognized and poorly studied. Little is known regarding the
most effective treatment. The impetus for research into this condition has waxed and waned,
possibly due to concerns regarding its distinctiveness from other disorders, especially social
anxiety disorder (SAD), schizoid personality disorder, and dependent personality disorder. The
prevailing paradigm subscribes to the “severity continuum hypothesis”, in which AVPD is
viewed essentially as a severe variant of SAD. However, areas of discontinuity have been
described, and there is support for retaining AVPD as a distinct diagnostic category. Recent
research has focused on the phenomenology of AVPD, factors of possible etiological
significance such as early parenting experiences, attachment style, temperament, and cognitive
processing. Self-concept, avoidant behavior, early attachments, and attachment style may
represent points of difference from SAD that also have relevance to treatment. Additional areas
of research not focused specifically on AVPD, including the literature on social cognition as it
relates to attachment and personality style, report findings that are promising for future research
aimed at better delineating AVPD and informing treatment.

DEPENDENT PERSONALITY DISORDER

Diagnostic Criteria ( ICD -10 )

F60.7 - Dependent Personality Disorder

(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;

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(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.

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

Diagnostic Criteria ( DSM-V )

301.6 – Dependent Personality Disorder

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 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.

Clinical Presentation

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 • Dependent personality disorder is characterized by a pervasive pattern of
dependent and submissive behavior.

• They cannot make decisions without an excessive amount of advice and

reassurance from others. They avoid positions of responsibility.

• They may describe being taken advantage of in social and employment situations,
and may sometimes be the victims of bullying.

• Their demeanour is passive, and this may show itself in posture, tone of voice,
etc.

• They have difficulty making long-term relationships owing to the emotional

demands they place on others.

• Distress is easily engendered by day-to-day problems of living owing to their

limited resources for problem-solving and decision-making.2

Case Study

Case One : This case study looks at the patient of a 27-year-old, white female named Sally. She
works as an administrative assistant whose work required extensive data entry. Sally’s mother
used her network to get this stable job for her daughter. Sally is consumed with pleasing her
mother and even asks for her mother’s advice on what to wear to the office each day. Sally
consistently worries about pleasing others and her colleagues at work, even at the expense to
herself, which leads to the diagnosis of dependent personality disorder. The degree to which her
self-destructive passivity and compliance at work stemmed from her early experiences within the
family are unclear, but her parents’ overprotectiveness likely played some role in the etiology of
her personality pathology.

Case Two : Ms. L., a 71-year-old woman with a past psychiatric history of over twenty-seven
recurrent hospitalizations for major depression and suicidal ideation, walked into the emergency
department herself, stating she needed help and had thoughts to jump in front of a moving car.
Among all prior suicidal ideations, having intent and a plan were reported, but attempts were
self-intercepted. The patient had an appropriate appearance, made good eye contact, yet spoke in

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a slow, low tone, with circumferential speech. She reported a depressed mood and had a
congruent flat affect, profusely tearing during the interview. Suicidal ideation was expressed
along with feelings and thoughts of worthlessness, after being laid off from her job as a nursing
home health aide three months prior, during the COVID-19 pandemic. “I want to kill myself; I
want to be with my mother, father, and brothers,” she exclaimed. The patient exhibited thought
blocking and, when speaking, expressed an overabundance of thought content filled with
hopelessness. She endorsed auditory hallucinations that instructed her to commit numerous self-
harm methods, which included jumping in front of a car, jumping out of a window, banging her
head on a desk, cutting her wrist, and overdosing on medications. The patient had limited insight
into her mental illness, stating, "I'm' here because I am afraid I'm going to kill myself. I don't
want to die, but I'm tired and don't want to be here anymore." She expressed good judgment and
was aware of the consequences of her actions, stating, "I'm afraid to leave the hospital because If
I do, I know what I will do to myself; my brother and my godson would be hurt if I took my
life.”

Further evaluation and follow-up interviews revealed a deeper cause of the patient's mental
illness. The patient's source of worthlessness was triggered by the loss of employment and
connected to the belief that she had no one to care for, stating, "I loved taking care of my patients
as a health aide. I took care of and raised all my brothers, nieces, and nephews, and they're all
grown now." In fact, according to the patient, and three historian sources of collateral
information gathered, the patient had never lived alone for any significant period. At the age of
10, the patient's mother suddenly separated from her father, then she, along with her eight
siblings, moved away. While her mother worked, the patient, as the eldest child, helped raise her
siblings. At the age of 20, the patient lived alone for five months, then subsequently had lived
and continued to live with various family members for the last 51 years, until the time of this
case study. There was a cyclical pattern of living with a family member to help clean, cook, or
raise their children as her own. Whenever the patient did not have someone to care for, a
downward spiral of emotional breakdown with thoughts of worthlessness would ensue. Suicidal
ideation then followed, triggered by two significant stressors from her past: The patient
witnessed her father die in her presence at the hospital due to myocardial infarction
complications. At age 15, the patient was forced to have a traumatic abortion using a metal

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hanger during the gestational age of 7 months. "My mother took away my chance to have a child
of my own. I could never have kids!” the patient exclaimed.

During the five-week treatment period in the psychiatry unit, the patient demonstrated cyclical
behaviors of attachment to peer patients with individual attention. For one peer patient, she
would help make a young woman’s bed daily; on another, she often provided parental-like
advice. On another peer with limited mobility, she accompanied him all day long with a
conversation. Each time, there was a departure of a peer, with whom the patient was attached to
help, she became depressed, tearfully returning to suicidal ideation, expressing, “all my friends
are leaving me here alone.” After a new attachment peer relationship formed with an existing or
new peer patient admitted to the ward, these feelings subsided. Immediately after being notified
of her discharge date, the patient spent time daily calling the parents of a 10-year-old child she
embraced as her godson, although she has not seen him in several years.

Case Research:

Personality disorders such as dependent personality disorder (DPD), among others, have shown
limited academic development in terms of a more in-depth understanding or subtypes that may
exist as a mental illness or associated condition. DPD was first published as a distinct personality
disorder in the Diagnostic and Statistical Manual for Mental Disorders, 3rd edition (DSM III)
psychiatry manual in 1980. Since its revision in the DSM IIIR in 1987, no significant
advancements have been proposed to date. This case study(Case Two) reported a patient with
suicidal ideation and offered a new type of DPD to advance personality disorders research. The
new subtype of dependent personality disorder has a few key characteristics of the traditional
disorder yet reveals features that mirror nearly opposite symptom criteria, making it unique as a
distinct subtype or possibly a separate personality disorder of its kind. The case study patient
report proposes comorbid diagnoses of adjustment disorder and dependent personality disorder,
the altruistic depressive type. Recommendations for further research were made.

ETIOLOGY

• Genetics: There could be a genetic predisposition toward developing certain

personality disorders.

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 • Childhood experiences: Adverse experiences during childhood, such as trauma or
neglect, can teach a child not to trust others, that the world is dangerous, or that
they are worthless. Parenting that provides little or no encouragement, or is
abusive, may encourage people to fear negative judgment.

• Temperament: Differences in development may influence how sensitive a person

is to what they experience, their ability to regulate emotions, or how the brain
responds to fear.

• Culture: The rates of different personality disorders vary globally, which suggests
that culture may play a role in the types of disorders that develop. (Sherrell,2023)

CAUSAL FACTORS

Obsessive Compulsive Personality Disorder

• Many Theorist take the five-factor theory approach to understand individuals with
OCPD where there are excessively high levels of conscientiousness.

• Leads to extreme devotion to work, perfectionism, and excessive controlling behaviors.

• Cloninger(1987) had an influential biological dimensional approach using the primary

dimensions of personality i.e. novelty, reward dependence and harm avoidance

• Modest genetic influence.

Avoidant Personality Disorder

• Some research suggests that avoidant personality may have its origins in an innate
“inhibited” temperament that leaves the infant and the child shy and inhibited in novel
and ambiguous situations.

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 • Traits prominent in avoidant personality disorder show a modest genetic influence.

• Genetic vulnerability partially shared with social phobia.

• Negative evaluation, introversion and neuroticism heritability are heightened.

• High in children who experience emotional abuse, rejection, or humiliation from parents
who are not particularly affectionate.

Dependent Personality Disorder

• Between 30-60 percent of the variance in dependent personality disorder symptoms

might be attributable to genetic factors.

• Personality traits such as neuroticism and agreeableness also have genetic components.

• It is possible that people with these partially genetically based predispositions to

dependence and anxiousness may be especially prone to the adverse effects of parents
who are authoritarian and overprotective.

• Cognitive theorists believed that core belief about weakness, competence and needing
others to survive may be responsible.

TREATMENT

Anankastic Personality Disorder/ Obsessive Compulsive Personality Disorder

• Psychotherapy: Patients are often aware of their suffering, and they seek treatment
on their own. Treatment is often long and complex, and countertransference
problems are common. Group therapy and behavior therapy occasionally offer
certain advantages.

• Pharmacotherapy: Clomipramine (Anafranil) and such serotonergic agents as

fluoxetine, may be useful if obsessive-compulsive signs and symptoms break
through.

Anxious [Avoidant] Personality Disorder

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 • Psychotherapy: Psychotherapeutic treatment depends on solidifying an alliance
with patients. Therapist eventually encourages a patient to move out into the
world to take what are perceived as great risks of humiliation, rejection, and
failure. Group therapy may help patients understand how their sensitivity to
rejection affects them and others. Assertiveness training is a form of behavior
therapy that may teach patients to express their needs openly and to enlarge their
self-esteem.

• Pharmacotherapy: They are helped by β-adrenergic receptor antagonists, such as

atenolol (Tenormin) to manage autonomic nervous system hyperactivity
especially when they approach feared situations.

Dependent Personality Disorder

• Psychotherapy: Insight-oriented therapies enable patients to understand the

antecedents of their behavior. Behavioral therapy, assertiveness training, family
therapy, and group therapy have all been used, with successful outcomes in many
cases.

• Pharmacotherapy: Pharmacotherapy has been used to deal with specific

symptoms, such as anxiety and depression. Patients who experience panic attacks
or who have high levels of separation anxiety may be helped by imipramine
(Tofranil). Benzodiazepines and serotonergic agents have also been useful.

EPIDEMIOLOGY

According DSM-V,

Anankastic (Obsessive Compulsive) Personality Disorder

An estimated prevalence ranging from 2 to 8 % (4.7%). It is more common in men than in

women and is diagnosed most often in oldest siblings.

Anxious [Avoidant] Personality Disorder

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The prevalence of the disorder is suggested to be about 2 to 3 percent of the general population.
No information on sex ratio or familial pattern. Infants classified as having a timid temperament
may be more susceptible to the disorder.

Dependent Personality Disorder

Dependent personality disorder is more common in women than in men, with and overall
estimated prevalence of 0.6 percent. ore common in young children than in older ones; chronic
physical illness in childhood may be most susceptible to the disorder.

In India

The overall prevalence rate of personality disorders in the country was an estimated 1.07%. The
cluster wise prevalence rate can be ranked as cluster c, cluster B, mixed presentation and lastly
cluster A. Among subtypes, anakastic had the highest prevalence rate of 18.1% and mixed of
16.7% (Gupta & Mattoo, 2012).

REFERENCES

American Psychiatric Association (2013). Diagnostic and statistical manual of Mental

Disorders (5th ed.). American Psychiatric Publishing.

Casey, P. , Kelly, B.(2019). Fish's Clinical Psychopathology (4th ed.). Cambridge University
Press.

Gupta, S. , Mattoo, S.K. (2012). Personality disorders: prevalence and demography at a

psychiatric outpatient in North India. International Journal of Social Psychiatry, 58(2).
DOI:10.1177/0020764010387548

Lei, H., Huang, L., Li, J., Liu, W., Fan, J., Zhang, X., … Rao, H. (2020). Altered spontaneous
brain activity in obsessive-compulsive personality disorder. Comprehensive Psychiatry, 96,
152144. doi:10.1016/j.comppsych.2019.1521

Luo, Y., Chen, L., Li, H., Dong, Y., Zhou, X., Qiu, L., Wang, K. (2020). Do Individuals With
Obsessive-Compulsive Disorder and Obsessive-Compulsive Personality Disorder Share

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 Similar Neural Mechanisms of Decision-Making Under Ambiguous Circumstances?
Frontiers in Human Neuroscience, 14. doi:10.3389/fnhum.2020.585086

Redden, S. A., Mueller, N. E., & Cougle, J. R. (2023). The impact of obsessive-compulsive
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Ruiz, P., Sadock, B. J., Sadock, V. A. (2015). Kaplan's & Sadock’s Synopsis of Psychiatry (11th
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Seretis, D., Hart, C.M. & Maguire, T. (2023). Validity of a Revised Obsessive-Compulsive
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