13.4 Fearful/Anxious Personality Disorders

The personality disorders in Cluster C—avoidant, dependent, and obsessive-compulsive personality disorders—share the feature of anxiety or fear. Although they have this superficial commonality, there is little overlap among the diagnostic criteria for these three disorders; this is in sharp contrast to the disorders within Cluster A (odd/eccentric) and those within Cluster B (dramatic/erratic), which have overlapping criteria. Nonetheless, people who have anxiety disorders and a comorbid personality disorder are most likely to have that personality disorder be from Cluster C (Friborg et al., 2013).

Avoidant Personality Disorder

The predominant characteristic of people with avoidant personality disorder is social inhibition—extreme shyness—that usually stems from feeling inadequate and being overly sensitive to negative evaluation (American Psychiatric Association, 2013). People with avoidant personality disorder are often characterized as shy, isolated, timid, or lonely.

The diagnostic criteria for avoidant personality disorder (see TABLE 13.18) all relate to the person’s predominant concern about embarrassing himself or herself during social interactions—perhaps by blushing or crying—and being socially rejected or humiliated. These fears, in turn, lead the person to limit social interactions.

People with avoidant personality disorder are so reluctant to engage in social interactions that they may turn down a promotion if the position requires increased social contact. And they are often hypervigilant for any indication of criticism or rejection. These fears and anxieties may cause them to behave in tense and fearful ways—for example, not talking about themselves for fear of what others might think—when they do interact with other people. This anxious way of relating to others may inadvertently elicit a mild version of the very reaction they fear—that others will evaluate them in a negative light. Among all people with personality disorders, those with avoidant personality disorder report the lowest quality of life (Cramer et al., 2003; Wilberg et al., 2009). Case 13.9 describes one person’s experience, and TABLE 13.19 provides additional facts about this disorder.

If you’re thinking that you’ve read about a disorder that seems similar to avoidant personality disorder earlier in this textbook, you’re correct. Avoidant personality disorder has much in common with social phobia (Chapter 6), and the symptoms of the two disorders overlap (Chambless et al., 2008; Tillfors et al., 2004). However, the criteria for avoidant personality disorder are broader than those for social phobia, and the symptoms include a more pervasive sense of inadequacy or inferiority and a reluctance to take risks (Skodol, 2005), as was true of Marcus in Case 13.9.

When making the diagnosis of avoidant personality disorder, clinicians must take cultural factors into account (American Psychiatric Association, 2013). For example, recent immigrants may exhibit symptoms of this disorder, perhaps because of language barriers or concerns about safety, and so clinicians must be sure to ask whether the behavior predates immigration. Because the three fearful/anxious personality disorders have not been studied in depth, we will discuss the underlying bases for and treatment of all three disorders after we consider specific features of each of them separately.

Dependent Personality Disorder

Dependent personality disorder is characterized by submissive and clingy behaviors, based on fear of separation. The DSM-5 definition notes that the clingy behaviors are intended to elicit attention, reassurance, and decisive behaviors from other people (American Psychiatric Association, 2013). These behaviors are not a temporary bid for attention or reassurance (like the behaviors of those with borderline or histrionic personality disorder) but are part of a chronic pattern of helpless behavior.

People with dependent personality disorder are chronically plagued by self-doubt and consistently underestimate their abilities (see TABLE 13.20 for the list of diagnostic criteria). Thus, they have a hard time making all kinds of decisions, from life-altering ones about what career to pursue to mundane decisions about what clothes to wear. They prefer to have other people make such choices for them. And because they are quick to believe they are wrong, they are likely to see any criticism or disapproval as proof of their negative beliefs about themselves.

This woman might just be bored, but meetings like the one shown in this photo make people with avoidant personality disorder uncomfortable. Symptoms of avoidant personality disorder and social phobia overlap, and people with either disorder are excessively concerned about being rejected by others or behaving in a way that leads them to feel humiliated. However, the social difficulties and feelings of inadequacy of people with avoidant personality disorder are generally more pervasive than those of people with other types of disorders.

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People with dependent personality disorder often don’t learn the skills needed to function independently and so are, in fact, dependent on others; they have reason to be concerned about living on their own. When a relationship ends, they typically leap into another one in order to ensure that they are not alone. Even while in an intimate relationship, they are often preoccupied with the possibility that the relationship will end, and they will have to fend for themselves. People with dependent personality disorder are most comfortable in relationships with people who take the initiative—and take responsibility. Not surprisingly, then, they often choose overprotective and dominating people to be their friends and partners, becoming passive in those relationships.

Generally, people who have dependent personality disorder have a limited social circle, consisting of only a few people on whom they depend, as is true of Matthew in Case 13.10. Once they have established a relationship, people with dependent personality disorder are hesitant to disagree with the other person for fear that he or she will withdraw emotional support. In fact, a person with this personality disorder may go to great lengths to maintain the support that the other person provides, even tolerating mental or physical abuse (American Psychiatric Association, 2013).

It is important to note that even if a person possesses enough of the characteristics to meet the diagnostic criteria in TABLE 13.20, he or she will not be diagnosed with dependent personality disorder unless these characteristics significantly impair functioning in major areas of life. TABLE 13.21 provides additional information about this disorder, although little is known about its etiology.

Obsessive-Compulsive Personality Disorder

Some people with obsessive-compulsive personality disorder may feel an urge to perfect a work-related task so strongly that they have difficulty stopping work.

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Obsessive-compulsive personality disorder is characterized by preoccupations with perfectionism, orderliness, and self-control, as well as low levels of flexibility and efficiency (American Psychiatric Association, 2013). This personality disorder is associated with the least disability (Skodol, Gunderson et al., 2002) and the highest obtained educational level (Torgersen et al., 2001). Rachel Reiland describes her father as having some elements of obsessive-compulsive personality disorder: He was strict, “coveted control,” and became enraged when events weren’t to his liking. Reiland herself had some elements of this disorder: “Once upon a time perfectionism was my noble aspiration. My perfectionism extended beyond academics or career. I also aspired to be the perfect mother, lover, and friend, always appropriate in all my emotional expressions” (2004.

People with obsessive-compulsive personality disorder can get so bogged down in details that they leave the most important elements to the last minute (see TABLE 13.22). For instance, when preparing a presentation, people with this disorder might spend hours creating a single PowerPoint slide, trying to get it perfect, and end up running out of time for organizing their talk. They can’t see the forest for the trees. For people with obsessive-compulsive personality disorder, decision making is a painful, long process; thus, once they’ve made a decision, they’re not likely to change their minds—which can end up making them appear rigid and inflexible. And, like Reiland’s father, when they are unable to control a situation, they may become angry, irritable, or upset.

Some (but not all) people who are workaholics may have obsessive-compulsive personality disorder—they may feel uncomfortable on vacations unless they take work along with them. And some with obsessive-compulsive personality disorder may spend excessive amounts of time on hobbies or household chores, striving for perfection and adhering to rules inflexibly. They may hold others to these same unrealistically stringent standards.

The relationships of people with obsessive-compulsive personality disorder are normally formal and serious; they are preoccupied with logic and intellect, are overly conscientious, and are intolerant of emotional or “illogical” behavior in others. Typically, people with obsessive-compulsive personality disorder feel uncomfortable with others who express emotions easily and openly. People with this disorder are not likely to express tender feelings or pay compliments. Other people often feel frustrated by their rigidity. In turn, people with obsessive-compulsive personality disorder have difficulty acknowledging the perspectives of others, as is true of Mr. V in Case 13.11. TABLE 13.23 provides additional information about this disorder.

Some workaholics have obsessive-compulsive personality disorder: They are perfectionistic and extremely orderly and organized. However, they can become so preoccupied with doing a job perfectly that they are inefficient or can’t complete the task. Moreover, when problems arise, they can be rigid and inflexible.

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Obsessive-compulsive personality disorder is distinguished from OCD by the absence of true obsessions and compulsions. Rather, those with obsessive-compulsive personality disorder are preoccupied with details—as was Mr. V when writing his master’s thesis—and are inflexible. Researchers are still trying to determine whether obsessive--compulsive personality disorder and OCD differ quantitatively or qualitatively. Research studies addressing this question have reported mixed findings (Eisen et al., 2006; Wu et al., 2006). Most people with one of the two disorders do not have the other (Mancebo et al., 2005).

Understanding Fearful/Anxious Personality Disorders

Virtually nothing is known about the neurological bases of fearful/anxious personality disorders, but the apparent similarity between these disorders and anxiety disorders might indicate that the amygdala is involved. In contrast, psychological factors associated with these disorders have been identified—fear and anxiety. Temperament can contribute to the development of any of these disorders, especially avoidant personality disorder (Joyce et al., 2003; Taylor et al., 2004). In fact, many of the factors related to social phobia are also associated with avoidant personality disorder, which makes sense, given the overlap in the symptoms of the two disorders. Moreover, people with both disorders have similar negative beliefs about themselves in relation to other people and avoid social situations for fear of embarrassing themselves (B. Meyer, 2002; Morey et al., 2003).

Cognitive and behavioral factors apparently contribute to all three fearful/anxious personality disorders. For all three, patients avoid situations that lead to discomfort and anxiety: With avoidant personality disorder, patients avoid social situations; with dependent personality disorder, they avoid making decisions and having responsibility; and with obsessive-compulsive personality disorder, they avoid making mistakes and experiencing strong emotions. The avoidance perpetuates the cognitive distortions because the patients’ fears go unchallenged (Beck et al., 2004; Farmer & Nelson-Gray, 2005).

Social factors apparently also contribute to these personality disorders. These factors include anxious or avoidant attachment style, which may have arisen in childhood as a result of particular interaction patterns with parents (Gude et al., 2004; Pincus & Wilson, 2001).

Treating Fearful/Anxious Personality Disorders

As for most other personality disorders, there is little research on the treatment of fearful/anxious personality disorders, and what research there is has focused primarily on avoidant personality disorder. The findings suggest that the best treatment for social phobia can also help people with avoidant personality disorder—namely, CBT that uses exposure to avoided stimuli as well as cognitive restructuring of maladaptive beliefs and strategies (Beck et al., 2004; Emmelkamp et al., 2006; Farmer & Nelson-Gray, 2005; Reich, 2000). Treatment may also include family or couples therapy to help family members change their responses to—and thus the consequences of—the patient’s maladaptive behaviors.

TABLE 13.24 summarizes the contrasting characteristics of the 10 personality disorders.