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Cluster C - Anxious Personality Patterns, and Why Diagnosing Personality Disorders Remains Complex
Abnormal Psychology · Chapter 22: Personality Disorders: Rigid Patterns That Impair FunctioningSection 22.4 · lesson 87 of 9715 min · free with a free account
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Next lesson: Factitious Disorders Defined: What They Are, How They Present, and Their Varieties →← Cluster B - Dramatic Personality Patterns: Impulsive, Unstable, and Self-FocusedNext lesson: Factitious Disorders Defined: What They Are, How They Present, and Their Varieties →
In this lesson
Fear-driven patterns - and the classification's criticisms at full strength.
- Describe avoidant, dependent, and obsessive-compulsive personality disorders
- Distinguish each from the state condition it resembles, and from a constrained situation
- State each criticism of the classification at its strongest, with the best response
- Describe good practice: formulation, transparency, and diagnosis as hypothesis
Transcript
Everything said in the video, section by section (1,960 words). Read along, or search it.
Personality Disorders: Rigid Patterns That Impair Functioning
Cluster C, and Why Diagnosis Stays Complex
This final section of chapter twenty-two has two parts. Part one covers Cluster C, the anxious or fearful patterns. Avoidant, dependent, and obsessive-compulsive personality disorders. Part two asks why diagnosing personality disorders remains complex. It sets out each criticism of the classification in its strongest form, with the best response, and ends with what good practice looks like.
Before You Begin
Clinical Terms, Not Everyday Adjectives
This material is educational and clinical. It is not a basis for self-diagnosis, or for diagnosing anyone else. If you are affected, please speak with a qualified professional. The terms in this chapter are clinical descriptions, arrived at through longitudinal assessment. They are not everyday adjectives. In particular, the popular use of obsessive-compulsive to mean tidy describes neither of the conditions that share the name.
Part 1: Cluster C
Anxious or Fearful - and Most Likely to Be Helped
Cluster C is described as the anxious or fearful grouping. Its three conditions share, loosely, a fear-driven organization of behavior. As with the other clusters, the grouping is descriptive, and weakly supported. But these conditions differ from the others in one practically important respect. People with these patterns are the most likely to present voluntarily for help, and the most likely to respond to treatment when they get it.
Avoidant Personality Disorder
Wanting Relationships, Avoiding Where They Form
Avoidant personality disorder is a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, from early adulthood and across contexts. It shows as avoiding work that involves significant contact with people, and restraint in relationships for fear of shame or ridicule. There is reluctance to take personal risks, and a view of oneself as socially inept or unappealing. The person typically wants relationships. This is not detachment. They avoid the situations in which relationships might form. And it should never be described as weakness, or a failure of character. It is a fear-driven avoidance pattern, of exactly the kind covered in the learning chapters, operating on interpersonal content. And it responds to the same principles.
Table 22.4.1
Avoidant Pattern or Social Anxiety?
The overlap with social anxiety disorder is substantial. Many people meet criteria for both. The avoidant pattern is pervasive, while social anxiety may be confined to specific situations. But the generalized form of social anxiety is very hard to separate from it. The clearest proposed distinction is self-concept. In the avoidant pattern, the person sees themselves as inept and unappealing in general. In social anxiety, fear focuses on evaluation in situations, with self-concept often intact elsewhere. The avoidant pattern is enduring, while social anxiety may fluctuate, though that distinction is weakened by the evidence on stability. And both are treated with cognitive and exposure-based work, the avoidant pattern usually for longer. That similarity is one argument that they are not distinct. Whether they are separate conditions, or the same difficulty at different severities, is disputed. But because the treatments are similar in kind, a clinician unsure which applies is not thereby unable to act.
Dependent Personality Disorder
A Need to Be Taken Care Of
Dependent personality disorder is a pervasive and excessive need to be taken care of, leading to submissive and clinging behavior, and fear of separation. It shows as difficulty making everyday decisions without excessive reassurance, difficulty disagreeing for fear of losing support, and difficulty starting things independently. It is not weakness either. This category attracts two specific criticisms. The first is cultural. Interdependence is normative in many communities. Mutual reliance within a family is a value, not a symptom. A criterion built around independent decision-making encodes a culturally particular expectation. Applied without regard to context, it records distance from that expectation as pathology. The second is that the diagnosis is applied unevenly by gender, with competing explanations that must be weighed. The counter-argument to both is that the impairment requirement does the work. Normative interdependence that costs nobody anything does not meet it. That answer is reasonable, though not complete, because impairment is itself judged against expectations.
In the Clinic
Formulate the Context Before Diagnosing Dependence
There is also an assessment step that is easy to skip. A person in a coercive or controlling relationship may present exactly as this category describes. Unable to decide alone, unable to disagree, and unable to act independently. Those features may accurately describe a constrained situation, rather than an enduring pattern. Diagnosing the person then pathologizes the constraint, and can obstruct help. So the question is not how much a person relies on others, but what would happen if they did otherwise. A person who defers because that is how their family works, and is not distressed or impaired, is describing a culture. A person who defers because disagreement has consequences is describing a situation, and the situation is what needs attention. Only when neither account fits does an enduring pattern become the best explanation. Asking what happens when the person disagrees, plainly, and with the other party not present, separates the three faster than any amount of history.
Obsessive-Compulsive Personality Disorder
Control at the Expense of Flexibility
Obsessive-compulsive personality disorder is a pervasive preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. It shows as preoccupation with rules, lists, and detail, until the purpose of the activity is lost. Perfectionism that prevents tasks being completed. Excessive devotion to work, at the expense of relationships and leisure. Rigidity about morality or procedure. Difficulty delegating, unless others submit to the person's method. And reluctance to discard. The efficiency cost is characteristic. The pattern is organized around control, and frequently produces less, rather than more.
Table 22.4.2
2 Conditions, One Name
This condition shares a name with obsessive-compulsive disorder, and very little else. In the personality disorder, obsessions and compulsions are absent. There are no intrusive unwanted thoughts, and no rituals. In obsessive-compulsive disorder, they define the condition. The clearest distinction is how the pattern is experienced. The personality pattern is ego-syntonic, experienced as a reasonable way to do things. Obsessive-compulsive disorder is ego-dystonic, experienced as unwanted and distressing. So they differ in what the person wants. In the personality pattern, usually that others adopt their standards. In the disorder, usually that the intrusions and rituals stop. And the personality pattern is enduring from early adulthood, while the disorder is often episodic, with an identifiable onset. And to repeat, calling someone tidy obsessive-compulsive describes neither condition. It trivializes a distressing condition, and misdescribes a pattern that is not mainly about tidiness at all.
Development, Course, Treatment
The Most Favorable Outcomes in the Chapter
Contributions across this cluster include temperament, especially behavioral inhibition, learning history, and adversity. The evidence is better than for Cluster A, and less developed than for borderline presentations. Course and outcome are the most favorable in the chapter. That follows partly from the conditions themselves, and partly from people presenting voluntarily. Cognitive and behavioral approaches target the beliefs about inadequacy, disagreement, or control that organize each pattern. Avoidant patterns add exposure-based work in interpersonal situations, delivered by a clinician. Interpersonal and schema-focused approaches address long-standing beliefs about self and others. Medication is by class only, and only for a co-occurring condition. The honest statement is that the evidence base is smaller than for anxiety conditions, and partly extrapolated from them. Outcomes are nonetheless generally good. And the risk here runs the other way from elsewhere in the chapter. Not that too much will be attempted, but that a person will get a brief intervention for the presenting anxiety, improve slightly, and be discharged with the enduring pattern untouched.
Part 2: Table 22.4.3
The Criticisms at Full Strength (1)
Part two. Four sections in, the classification is still contested. Here is each criticism in its strongest form, with the best response, and what remains open. Read across each row. The trait-state boundary. An enduring pattern cannot be reliably separated from a persistent state, and services lack the information needed. The response is that structured assessment and collateral information improve reliability. Still open is whether ordinary services can realistically get that information. Threshold arbitrariness. There is no natural boundary, and the required number of features is convention. The response is that all thresholds are conventions, and this one predicts service use and outcome. Still open is whether usefulness justifies a line that decides access to care. Heterogeneity and overlap. Two people with one diagnosis may share few features. The response is that this is real, and it is why the dimensional model was developed. The open question is whether speed of communication is worth the cost in accuracy. And stability. A category defined by stability is not stable. The response is that the definition can be revised without abandoning the concept, and change is good news clinically. Still open is what enduring means, if patterns routinely stop meeting criteria.
Table 22.4.3 (continued)
The Criticisms at Full Strength (2)
Three more criticisms. Cultural and gender bias. Application differs across groups, and several criteria encode particular expectations of independence, emotional expression, and achievement. The response is that the impairment requirement and cultural-context criterion exist to prevent exactly this. Still open is whether those safeguards survive contact with practice. Stigma and harm. The documented effect on care may exceed the diagnosis's clinical value. The response is that the harm attaches to how the diagnosis is used, and that effective treatments exist because it was defined. Still open is whether a category so readily misused can be made safe in ordinary services. And the boundary with trauma. Several presentations may be better understood as adaptations to sustained adversity. The response is that this accounts for many cases, but not all. Still open is whether the two frameworks describe different things, or the same thing differently.
The Strongest Defense
Why the Categories Are Retained
Set against all of that, the case for keeping the categories rests on four claims. Clinicians need some way to describe enduring interpersonal and self-related patterns, because those patterns are real features of people's difficulties. The descriptions predict something, including treatment response, service use, and course. The alternative of ignoring these patterns was tried, and it served people badly. Distress was treated episodically, and the reason it kept returning went unaddressed. And the effective treatments for borderline presentations exist because a category was defined, clearly enough for treatments to be developed and tested. The strongest evidence in this chapter is a product of the system its critics object to. The dimensional model would fix the threshold, heterogeneity, overlap, and coverage problems at once. It would not fix the trait-state problem, which is about assessment, and it would not by itself fix stigma. The international classification's move to a dimensional approach is a live natural experiment. Its consequences for reliability, access, stigma, and treatment evidence are not yet known.
What Good Practice Looks Like
4 Commitments
Good practice comes down to four commitments. Formulation over labeling. An account of how the pattern developed, what maintains it, and what it costs. Transparency with the person. Telling them their diagnosis, what it means, what it does not mean, and what the evidence says about outcome. Concealing it protects no one, and guarantees they meet it later in a worse form. Attention to context and adversity. Assessing the situation a person is in, before concluding that the pattern is in the person. And treating the diagnosis as a hypothesis. Recorded provisionally, revisited, and revised, which the stability evidence positively requires, and which record systems rarely encourage.
Table 22.4.4 - Chapter 22 Synthesis
A Hypothesis About a Pattern
Here is chapter twenty-two in summary. For the concept, assess longitudinally, once acute conditions are stable, and treat the diagnosis as a hypothesis. For Cluster A, distinguish autism, the prodrome, and well-founded suspicion, and engage through predictability. For Cluster B, treat it, watch the language, and provide structure, consistency, and a crisis plan. For Cluster C, do not stop at the presenting anxiety, and assess context before diagnosing dependence. And hold the classification itself lightly, formulate rather than label, and say what is uncertain. This is the area of the classification where the gap between what a diagnosis is meant to do, and what it actually does in services, is widest. The categories describe something real. They are also used, more than any others, as descriptions of people rather than patterns. So take this one thing from the chapter. The diagnosis is a hypothesis about a pattern. It is revisable, and it is never an account of who someone is.
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