The cluster of “anxious” personality disorders includes the avoidant, dependent, and obsessive-compulsive personality disorders. People with these patterns typically display anxious and fearful behavior. Although many of the symptoms of these personality disorders are similar to those of the anxiety and depressive disorders, researchers have not found direct links between this cluster and those disorders (O’Donohue et al., 2007). As with most of the other personality disorders, research support for the various explanations is very limited. At the same time, treatments for these disorders appear to be modestly to moderately helpful—considerably better than for other personality disorders.

People with avoidant personality disorder are very uncomfortable and inhibited in social situations, overwhelmed by feelings of inadequacy, and extremely sensitive to negative evaluation (APA, 2013). They are so fearful of being rejected that they give no one an opportunity to reject them—or to accept them either:

People like Malcolm actively avoid occasions for social contact. At the center of this withdrawal lies not so much poor social skills as a dread of criticism, disapproval, or rejection. They are timid and hesitant in social situations, afraid of saying something foolish or of embarrassing themselves by blushing or acting nervous. Even in intimate relationships they express themselves very carefully, afraid of being shamed or ridiculed.

People with this disorder believe themselves to be unappealing or inferior to others. They exaggerate the potential difficulties of new situations, so they seldom take risks or try out new activities. They usually have few or no close friends, though they actually yearn for intimate relationships, and frequently feel depressed and lonely. As a substitute, some develop an inner world of fantasy and imagination(Millon, 2011).

Avoidant personality disorder is similar to social anxiety disorder (see Chapter 5), and many people with one of these disorders also experience the other (Eikenaes et al., 2013). The similarities include a fear of humiliation and low confidence. Some theorists believe that there is a key difference between the two disorders—namely, that people with social anxiety disorder primarily fear social circumstances, while people with the personality disorder tend to fear close social relationships (Lampe & Sunderland, 2013; Kantor, 2010). Other theorists, however, believe that the two disorders reflect the same core of psychopathology and should be combined (Eikenaes et al., 2013; Herbert, 2007).

Around 2.4 percent of adults have avoidant personality disorder, men as frequently as women (APA, 2013; Sansone & Sansone, 2011). Many children and teenagers are also painfully shy and avoid other people, but this is usually just a normal part of their development.

How Do Theorists Explain Avoidant Personality Disorder?Theorists often assume that avoidant personality disorder has the same causes as anxiety disorders—such as early traumas, conditioned fears, upsetting beliefs, or biochemical abnormalities. However, with the exception of social anxiety disorder, research has not yet tied the personality disorder directly to the anxiety disorders (Herbert, 2007). Psychodynamic, cognitive, and behavioral explanations of avoidant personality disorder are the most popular among clinicians.

Psychodynamic theorists focus mainly on the general sense of shame that people with avoidant personality disorder feel (Svartberg & McCullough, 2010). Some trace the shame to childhood experiences such as early bowel and bladder accidents. If parents repeatedly punish or ridicule a child for having such accidents, the child may develop a negative self-image. This may lead to the child’s feeling unlovable throughout life and distrusting the love of others.

Similarly, cognitive theorists believe that harsh criticism and rejection in early childhood may lead certain people to assume that others in their environment will always judge them negatively. These people come to expect rejection, misinterpret the reactions of others to fit that expectation, discount positive feedback, and generally fear social involvements—setting the stage for avoidant personality disorder (Rees & Pritchard, 2013; Weishaar & Beck, 2006; Beck et al., 2004). In several studies, participants with this disorder were asked to recall their childhood, and their descriptions supported both the psychodynamic and the cognitive theories (Carr & Francis, 2010; Herbert, 2007). They remembered, for example, feeling criticized, rejected, and isolated; receiving little encouragement from their parents; and experiencing few displays of parental love or pride.

Behavioral theorists suggest that people with avoidant personality disorder typically fail to develop normal social skills, a failure that helps maintain the disorder. In support of this position, several studies have found social skills deficits among people with avoidant personality disorder (Kantor, 2010; Herbert, 2007). Most behaviorists agree, however, that these deficits first develop as a result of the individuals avoiding so many social situations.

Treatments for Avoidant Personality DisorderPeople with avoidant personality disorder come to therapy in the hope of finding acceptance and affection. Keeping them in treatment can be a challenge, however, for many of them soon begin to avoid the sessions. Often they distrust the therapist’s sincerity and start to fear his or her rejection. Thus, as with several of the other personality disorders, a key task of the therapist is to gain the person’s trust (Colli et al., 2014; Leichsenring & Salzer, 2014).

Beyond building trust, therapists tend to treat people with avoidant personality disorder much as they treat people with social anxiety disorder and other anxiety disorders (Svartberg, Stiles, & Seltzer, 2004; Markovitz, 2001). Such approaches have had at least modest success (Kantor, 2010; Porcerelli et al., 2007). Psychodynamic therapists try to help clients recognize and resolve the unconscious conflicts that may be operating (Leichsenring & Salzer, 2014; Messer & Abbass, 2010). Cognitive therapists help them change their distressing beliefs and thoughts, carry on in the face of painful emotions, and improve their self-image (Rees & Pritchard, 2013; Weishaar & Beck, 2006; Beck et al., 2004). Behavioral therapists provide social skills training as well as exposure treatments that require people to gradually increase their social contacts (Herbert, 2007; Farmer & Nelson-Gray, 2005). Group therapy formats, especially groups that follow cognitive and behavioral principles, have the added advantage of providing clients with practice in social interactions (Herbert et al., 2005). Antianxiety and antidepressant drugs are sometimes useful in reducing the social anxiety of people with the disorder, although the symptoms may return when medication is stopped (Ripoll et al., 2011; Fava et al., 2002).

People with dependent personality disorder have a pervasive, excessive need to be taken care of (APA, 2013). As a result, they are clinging and obedient, fearing separation from their parent, spouse, or other person with whom they are in a close relationship. They rely on others so much that they cannot make the smallest decision for themselves. Matthew is a case in point.

It is normal and healthy to depend on others, but those with dependent personality disorder constantly need assistance with even the simplest matters and have extreme feelings of inadequacy and helplessness. Afraid that they cannot care for themselves, they cling desperately to friends or relatives.

As you just observed, people with avoidant personality disorder have difficulty initiating relationships. In contrast, people with dependent personality disorder have difficulty with separation. They feel completely helpless and devastated when a close relationship ends, and they quickly seek out another relationship to fill the void. Many cling persistently to relationships with partners who physically or psychologically abuse them (Loas et al., 2011).

Lacking confidence in their own ability and judgment, people with this disorder seldom disagree with others and allow even important decisions to be made for them (Bornstein, 2012, 2007; Millon, 2011). They may depend on a parent or spouse to decide where to live, what job to have, and which neighbors to befriend. Because they so fear rejection, they are overly sensitive to disapproval and keep trying to meet other people’s wishes and expectations, even if it means volunteering for unpleasant or demeaning tasks.

Many people with dependent personality disorder feel distressed, lonely, and sad; often they dislike themselves. Thus they are at risk for depressive, anxiety, and eating disorders (Bornstein, 2012, 2007). Their fear of separation and their feelings of helplessness may leave them particularly prone to suicidal thoughts, especially when they believe that a relationship is about to end (Bornstein, 2012; Kiev, 1989).

Surveys suggest that fewer than 1 percent of the population experience dependent personality disorder (APA, 2013; Sansone & Sansone, 2011). For years, clinicians have believed that more women than men display this pattern, but some research suggests that the disorder is just as common in men (APA, 2013).

How Do Theorists Explain Dependent Personality Disorder?Psychodynamic explanations for dependeng personality disorder are very similar to those for depression (Svartberg & McCullough, 2010). Freudian theorists argue, for example, that unresolved conflicts during the oral stage of development can give rise to a lifelong need for nurturance, thus heightening the likelihood of a dependent personality disorder (Bornstein, 2012, 2007, 2005). Similarly, object relations theorists say that early parental loss or rejection may prevent normal experiences of attachment and separation, leaving some children with fears of abandonment that persist throughout their lives (Caligor & Clarkin, 2010). Still other psychodynamic theorists suggest that, to the contrary, many parents of people with this disorder were overinvolved and overprotective, thus increasing their children’s dependency, insecurity, and separation anxiety (Sperry, 2003).

Behaviorists propose that parents of people with dependent personality disorder unintentionally rewarded their children’s clinging and “loyal” behavior, while at the same time punishing acts of independence, perhaps through the withdrawal of love. Alternatively, some parents’ own dependent behaviors may have served as models for their children (Bornstein, 2012, 2007).

Cognitive theorists identify two maladaptive attitudes as helping to produce and maintain this disorder: (1) “I am inadequate and helpless to deal with the world,” and (2) “I must find a person to provide protection so I can cope.” Dichotomous (black-and-white) thinking may also play a key role: “If I am to be dependent, I must be completely helpless,” or “If I am to be independent, I must be alone.” Such thinking prevents sufferers from making efforts to be autonomous (Borge et al., 2010; Weishaar & Beck, 2006; Beck et al., 2004).

Treatments for Dependent Personality DisorderIn therapy, people with dependent personality disorder usually place all responsibility for their treatment and well-being on the clinician. Thus a key task of therapy is to help patients accept responsibility for themselves (Colli et al., 2014; Gutheil, 2005). Because the domineering behaviors of a spouse or parent may help foster a patient’s symptoms, some clinicians suggest couple or family therapy as well, or even separate therapy for the partner or parent (Lebow & Uliaszek, 2010; Nichols, 2004).

Treatment for dependent personality disorder can be at least modestly helpful. Psychodynamic therapy for this pattern focuses on many of the same issues as therapy for depressed people, including the transference of dependency needs onto the therapist (Svartberg & McCullough, 2010). Cognitive-behavioral therapists combine behavioral and cognitive interventions to help the clients take control of their lives. On the behavioral end, the therapists often provide assertiveness training to help the individuals better express their own wishes in relationships (Farmer & Nelson-Gray, 2005). On the cognitive end, the therapists also try to help the clients challenge and change their assumptions of incompetence and helplessness (Borge et al., 2010; Weishaar & Beck, 2006; Beck et al., 2004). Antidepressant drug therapy has been helpful for people whose personality disorder is accompanied by depression (Fava et al., 2002).

As with avoidant personality disorder, a group therapy format can be helpful because it provides opportunities for the client to receive support from a number of peers rather than from a single dominant person (Perry, 2005; Sperry, 2003). In addition, group members may serve as models for one another as they practice better ways to express feelings and solve problems.

People with obsessive-compulsive personality disorder are so preoccupied with order, perfection, and control that they lose all flexibility, openness, and efficiency (APA, 2013). Their concern for doing everything “right” impairs their productivity, as in the case of Joseph:

In Joseph’s concern with rules and order and doing things right, he has trouble seeing the larger picture. When faced with a task, he and others who have obsessive-compulsive personality disorder may become so focused on organization and details that they fail to grasp the point of the activity. As a result, their work is often behind schedule (some seem unable to finish any job), and they may neglect leisure activities and friendships.

People with this personality disorder set unreasonably high standards for themselves and others. Their behaviors extend well beyond the realm of conscientiousness. They can never be satisfied with their performance, but they typically refuse to seek help or to work with a team, convinced that others are too careless or incompetent to do the job right. Because they are so afraid of making mistakes, they may be reluctant to make decisions.

They also tend to be rigid and stubborn, particularly in their morals, ethics, and values. They live by a strict personal code and use it as a yardstick for measuring others. They may have trouble expressing much affection, and their relationships are sometimes stiff and superficial. In addition, they are often stingy with their time or money. Some cannot even throw away objects that are worn out or useless (APA, 2013).

According to surveys, as many as 7.9 percent of the adult population display obsessive-compulsive personality disorder, with white, educated, married, and employed people receiving the diagnosis most often (APA, 2013; Sansone & Sansone, 2011). Men are twice as likely as women to display the disorder.

Many clinicians believe that obsessive-compulsive personality disorder and obsessive-compulsive disorder are closely related. Certainly, the two disorders share a number of features, and many people who suffer from one of the disorders meet the diagnostic criteria for the other disorder (Pinto et al., 2014; Gordon et al., 2013). However, it is worth noting that people with the personality disorder are more likely to suffer from either major depressive disorder, generalized disorder, or a substance use disorder than from obsessive-compulsive disorder (APA, 2013; Pena-Garijo et al., 2013; Pinto et al., 2008). In fact, researchers have not consistently found a specific link between obsessive-compulsive personality disorder and obsessive-compulsive disorder (Starcevic & Brakoulias, 2014; Gordon et al., 2013).

How Do Theorists Explain Obsessive-Compulsive Personality Disorder?Most explanations of obsessive-compulsive personality disorder borrow heavily from those of obsessive-compulsive disorder, despite the doubts concerning a link between the two disorders. As with so many of the personality disorders, psychodynamic explanations dominate and research evidence is limited.

Freudian theorists suggest that people with obsessive-compulsive personality disorder are anal retentive. That is, because of overly harsh toilet training during the anal stage, they become filled with anger, and they remain fixated at this stage. To keep their anger under control, they persistently resist both their anger and their instincts to have bowel movements. In turn, they become extremely orderly and restrained; many become passionate collectors. Other psychodynamic theorists suggest that any early struggles with parents over control and independence may ignite the aggressive impulses at the root of this personality disorder (Millon, 2011; Bartz et al., 2007).

Cognitive theorists have little to say about the origins of obsessive-compulsive personality disorder, but they do propose that illogical thinking processes help keep it going (Weishaar & Beck, 2006; Beck et al., 2004). They point, for example, to dichotomous thinking, which may produce rigidity and perfectionism. Similarly, they note that people with this disorder tend to misread or exaggerate the potential outcomes of mistakes or errors.

Treatments for Obsessive-Compulsive Personality DisorderPeople with obsessive-compulsive personality disorder do not usually believe there is anything wrong with them. They therefore are not likely to seek treatment unless they are also suffering from another disorder, most frequently an anxiety disorder or depression, or unless someone close to them insists that they get treatment (Bartz et al., 2007). Because of this, therapists often feel as though they must “win over” and engage the clients in the therapy process (Colli et al., 2014).

People with obsessive-compulsive personality disorder often respond well to psychodynamic or cognitive therapy (Messer & Abbass, 2010; Svartberg & McCullough, 2010; Weishaar & Beck, 2006). Psychodynamic therapists typically try to help these clients recognize, experience, and accept their underlying feelings and insecurities, and perhaps take risks and accept their personal limitations. Cognitive therapists focus on helping the clients to change their dichotomous—”all or nothing”—thinking, perfectionism, indecisiveness, procrastination, and chronic worrying. A number of clinicians report that people with obsessive-compulsive personality disorder, like those with obsessive-compulsive disorder, respond well to SSRIs, the serotonin-enhancing antidepressant drugs; however, researchers have yet to study this issue fully (Pinto et al., 2008).