C H A P T E R 19

Cluster C Personality Disorders

Courtney Eaves

A 23-year-old graduate student, who is in her first semester of pharmacy school, presents to
the student mental health clinic at the request of her parents. She complains of having con-
sistent problems turning in assignments on time and is now failing several classes. This has
caused more stress, which only seems to be worsening the problems she is having with school.
She is spending an excessive amount of time on school at the expense of her interpersonal
relationships.

What other information is important to know?

Obtaining more detailed information about the presenting complaint is the most important
first step. Asking why the patient is having trouble turning in assignments is critical in deter-
mining the next steps in treatment for this patient. Additionally, you would want to gather
a thorough psychiatric and medical history (as well as screening for both depression and
anxiety).

When the patient starts an assignment, she has a very specific way of studying the information,
which includes rewriting much of the information and then highlighting it in multiple colors. She
explains this process to you in great detail. She has a few friends and is dating a fellow student
but reports her primary focus is school, often at the expense of her social life. She speaks of her
boyfriend in a formal and serious manner and her affect is constricted. She endorses some anxiety
about her grades and school and also seems to worry about other aspects of her life. She reports
no medical issues and no significant psychiatric history.

You suspect the patient is suffering from obsessive-compulsive personality disorder; what other
questions should be asked to confirm the diagnosis?
The patient is presenting with several criteria for this diagnosis, including preoccupation with
lists and organization, perfectionism interfering with task completion, and an excess devotion
to work/school. Additional criteria to ask about, that may be interfering with her functioning,
include being inflexible about morals and ethics, being very careful about spending money, having
trouble throwing out items of insignificance, and having difficulty working in groups because oth-
ers will not do things her way. She may come across as stubborn to others because of her rigidity
in thinking.

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TABLE 19.1  ■  Distinguishing OCPD from OCD

Obsessive-Compulsive Personality Disorder Obsessive-Compulsive Disorder
Preoccupation with order and perfectionism, Irrational thoughts and behaviors that are
inflexibility, difficulty working with others due to lack repeated over and over
of control
Behaviors persistent and unchanged over time Symptoms tend to fluctuate over time
Belief that their behaviors serve a positive purpose in their Patients distressed by their obsessions
lives and/or compulsions
Less likely to seek professional help Often seek professional help

How is obsessive-compulsive personality disorder distinguished from obsessive-compulsive

disorder (see Table 19.1)?

CLINICAL PEARL STEP 2/3

OCPD is ego-syntonic, meaning the feelings and behaviors are in harmony with the patient’s
own goals and self-image, whereas OCD is ego-dystonic, meaning the accompanying obses-
sions and/or compulsions are in conflict with the person’s needs or self-image. This explains
why those with OCD often seek treatment on their own, whereas those with OCPD may take
more time to realize the need for intervention by a physician or therapist.

You assess for the above-mentioned aspects of this disorder. The patient tells you that she was re-
cently assigned a group project (due next week), and she is having significant difficulty working with
the others because they have their own ideas and plans for the project. She feels unable to control the
project or work with the other members. She would much prefer to complete the assignment alone.
You discuss with the patient her preliminary diagnosis and go over the treatment options.

What are the treatment options for OCPD?

Psychotherapy is the mainstay of treatment for OCPD. Both cognitive-behavioral therapy (CBT)
and psychodynamic therapy can be helpful. Increasing insight into behaviors, and how those
behaviors affect the person, is one of the most important aspects of therapy. Because people with
this disorder generally lack flexibility in daily routines and in expectations of others, therapy can
be quite difficult at times. If there is comorbid depression or anxiety (because of how this disorder
is negatively affecting life), an antidepressant medication may also be prescribed.

What are the most common defense mechanisms used in obsessive-compulsive personality disorder
that can be addressed in therapy (see Table 19.2)?

Your patient starts going to psychotherapy and focuses on the relationship between her thoughts,
feelings, and behaviors. She is able to gain more insight into why she has difficulty working with
others in a group setting, as well as how to study more effectively (e.g., purposefully cutting out
excessive list making and highlighting). She also begins to make a conscious effort at interper-
sonal relationships and reports to her therapist weekly on how this is going. The patient and
her psychiatrist also agree on starting an SSRI for the patient’s continued anxiety surrounding
school.
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TABLE 19.2  ■  Defense Mechanisms in OCPD

Defense Mechanism Definition
Rationalization Attempting to explain or justify
behavior or an attitude with logical
reasons, even if these are not
appropriate
Intellectualization Reasoning is used to block confrontation
with an unconscious conflict and its
associated emotional stress
Reaction formation Acting in the opposite manner to
disturbing or socially unacceptable
thoughts or emotions
Isolation of affect Attempting to avoid a painful thought or
feeling by objectifying and emotionally
detaching oneself from the feeling
Undoing Trying to reverse or “undo” a thought
or feeling by performing an action
that signifies an opposite feeling
than the original thought or feeling
Example
A college student constantly
cancels plans with friends and
blames it on having too much
schoolwork to do
A person told they have cancer
asks for details on the
probability of survival and the
success rates of various drugs
A young woman who feels
she may be gay joins a very
conservative church
Someone fails a major test but
shows minimal or no outward
emotion of the disappointment
A person strongly dislikes
someone and then buys the
person a gift

CLINICAL PEARL STEP 2/3

OCPD is part of the cluster C personality disorders that are generally characterized as anxious
and fearful disorders (or “worried”). People with any of the cluster C personality disorders all
have an overwhelming level of anxiety.

What are the other cluster C personality disorders and how would you diagnose and treat them?
The three personality disorders in this cluster are avoidant, dependent, and obsessive-compulsive
personality disorders. Avoidant personality disorder involves a patient being hypersensitive to rejec-
tion and often misinterpreting social cues because of low self-esteem. This leads to a lack of close
friendships and feelings of loneliness. These patients often will not seek out new friendships or
put themselves in social situations because of fear of not being liked. Those with dependent per-
sonality disorder feel that they must rely on others for help with decision-making and constantly
worry about loss or abandonment from those they are close to. They may stay in abusive or ne-
glectful relationships because of this fear. As with OCPD, avoidant and dependent personality
disorders are treated with psychotherapy primarily. Often antidepressants, particularly SSRIs, are
prescribed for associated anxiety or depression that accompanies the personality disorder.

What is the cause of cluster C personality disorders?

There is no known cause of cluster C disorders, but there appears to be a genetic association re-
lated to family members with anxiety disorders. It is common to find a first-degree relative with
an anxiety disorder when conducting a thorough family history.

How can you differentiate avoidant personality disorder from schizoid personality disorder?
Those with schizoid personality disorder voluntarily choose to withdraw socially and maintain
few friendships. Those with avoidant personality disorder have a desire for social relationships but
find establishing and maintaining these relationships very difficult because of fear of rejection and
feelings of inadequacy.
140 PSYCHIATRY MORNING REPORT: BEYOND THE PEARLS

CLINICAL PEARL STEP 2/3

Those with avoidant personality disorder want friends but are too anxious to make and keep
relationships, whereas those with schizoid personality disorder are okay with not having
friends and often appear indifferent and apathetic.

BEYOND THE PEARLS:

• OCPD is diagnosed twice as much in men versus women.

• OCPD is the most common personality disorder with a prevalence of 7% to 8% in the
general population.
• Prevalence of avoidant personality disorder is about 2%.
• Prevalence of dependent personality disorder is about 0.5% to 1%.
• All personality disorders, including those in cluster C, must develop by early adulthood.

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