Cluster C Disorders PDF

CLUSTER C DISORDERS DR. FARIHA ISHRAT ULLAH  CLUSTER C Disorders People with these patterns typically display anxious and fearful behavior. The cluster of “anxious” personality disorders includes the 1. Avoidant personality disorder 2. Dependent personality disorder 3. Obs...

CLUSTER C DISORDERS DR. FARIHA ISHRAT ULLAH  CLUSTER C Disorders People with these patterns typically display anxious and fearful behavior. The cluster of “anxious” personality disorders includes the 1. Avoidant personality disorder 2. Dependent personality disorder 3. Obsessive-compulsive personality disorder.  CASE STUDY Sally, a 35-year-old librarian, lived a relatively isolated life and had few acquaintances and no close personal friends. From childhood on, she had been very shy and had withdrawn from close ties with others to keep from being hurt or criticized. Two years before she entered therapy, she had had a date to go to a party with an acquaintance she had met at the library. The moment they had arrived at the party, Sally had felt extremely uncomfortable because she had not been “dressed properly.” She left in a hurry and refused to see her acquaintance again. In the early treatment sessions, she sat silently much of the time, finding it too difficult to talk about herself. After several sessions, she grew to trust the therapist, and she related numerous incidents in her early years in which she had been “devastated” by her alcoholic father’s obnoxious behavior in public. Although she had tried to keep her school friends from knowing about her family problems, when this had become impossible, she instead had limited her friendships, thus protecting herself from possible embarrassment or criticism. When Sally first began therapy, she avoided meeting people unless she could be assured that they would “like her.” With therapy that focused on enhancing her assertiveness and social skills, she made some progress in her ability to approach people and talk with them.  AVOIDANT PERSONALITY DISORDER Theodore Millon (1981) initially proposed this diagnosis. People with avoidant personality disorder are very uncomfortable and inhibited in social situations, overwhelmed by feelings of inadequacy, and extremely sensitive to negative evaluation. Because of their hypersensitivity to, and fear of, criticism and rebuff, they do not seek out other people, yet they desire affection and are often lonely and bored. Feeling inept and socially inadequate are the two most prevalent and stable features of avoidant personality disorder. The avoidant behaviors can also adversely affect occupational functioning because these individuals try to avoid the types of social situations that may be important for meeting the basic demands of the job or for advancement. Prevalence of this disorder has been estimated at 2.4 percent in the general population (men as frequently as women).  DSM 5 Criteria 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.  Etiology Some research suggests that avoidant personality may have its origins in an innate “inhibited” temperament that leaves the infant and child shy and inhibited in novel and ambiguous situations modest genetic influence (Reichborn-Kjennerud et al., 2006), and that the genetic vulnerability for avoidant personality disorder is at least partially shared with that for social phobia. introversion and neuroticism are also both elevated and they too are moderately heritable. Millon (1981), for example, suggests that these individuals may be born with a difficult temperament or personality characteristics. As a result, their parents may reject them, or at least not provide them with enough early, uncritical love. This rejection, in turn, may result in low self-esteem and social alienation, conditions that persist into adulthood.  Psychodynamic theorists focus mainly on the general sense of shame that people with avoidant personality disorder feel. 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. 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. These individuals are likely to predict and interpret the rejection as caused solely by their personal deficiencies. Behavioral theorists suggest that people with avoidant personality disorder typically fail to develop normal social skills, a failure that helps maintain the disorder.  Treatment Psychodynamic therapists try to help clients recognize and resolve the unconscious conflicts that may be operating. Cognitive therapists help them change their distressing beliefs and thoughts, carry on in the face of painful emotions, and improve their self- image. Behavioral therapists provide social skills training as well as exposure treatments that require people to gradually increase their social contacts. Group therapy formats, especially groups that follow cognitive and behavioral principles, have the added advantage of providing clients with practice in social interactions. 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.  Case Study Matthew is a 34-year-old single man who lives with his mother and works as an accountant. He is... very unhappy after having just broken up with his girlfriend. His mother had disapproved of his marriage plans.... Matthew felt trapped and forced to choose between his mother and his girlfriend, and because “blood is thicker than water,” he had decided not to go against his mother’s wishes.... His mother... is a very domineering woman.... Matthew is afraid of disagreeing with [her] for fear that she will not be supportive of him and he will then have to fend for himself. He criticizes himself for being weak.... He alternates between resentment and a “Mother knows best” attitude. He feels that his own judgment is poor. Matthew works at a job several grades below what his education and talent would permit. On several occasions he has turned down promotions because he didn’t want the responsibility of having to supervise other people or make independent decisions. He has worked for the same boss for 10 years... and is... highly regarded as a dependable and unobtrusive worker. He has two very close friends whom he has had since early childhood. He has lunch with one of them every single workday and feels lost if his friend is sick and misses a day. Matthew is the youngest of four children.... He was “babied and spoiled” by his mother and elder sisters. He had considerable separation anxiety as a child... difficulty falling asleep unless his mother stayed in the room... and unbearable homesickness when he occasionally tried “sleepovers.” As a child he was teased by other boys because of his lack of assertiveness and was often called a baby. He has lived at home his whole life except for 1 year of college, from which he returned because of homesickness.  Dependent Personality Disorder People with dependent personality disorder rely on others to make ordinary decisions as well as important ones, which results in an unreasonable fear of abandonment. Individuals with dependent personality disorder sometimes agree with other people when their own opinion differs so as not to be rejected (Bornstein, 2012). Their desire to obtain and maintain supportive and nurturant relationships may lead to their other behavioral characteristics, including submissiveness, timidity, and passivity. They often fail to get appropriately angry with others because of a fear of losing their support, which means that people with dependent personalities may remain in psychologically or physically abusive relationships. In terms of five factor model, dependent personality disorder is associated with high levels of neuroticism and agreeableness Estimates are that dependent personality disorder occurs in 1 to 2 percent of the population and is more common in women than in men.  DSM 5 Criteria 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. 6. Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself. 7. Urgently seeks another relationship as a source of care and support when a close relationship ends. 8. Is unrealistically preoccupied with fears of being left to take care of himself or herself  Etiology Personality traits such as neuroticism and agreeableness that are also prominent in dependent personality disorder also have a genetic component. 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. 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. 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. 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. Cognitive theorists describe the underlying maladaptive schemas for these individuals as involving core beliefs about weakness and competence and needing others to survive (P. S. Rasmussen, 2005), such as, “I am completely helpless” and “I can function only if I have access to somebody competent” According to Beck (2015), the dependent personality is rooted in basic assumptions about the self and the world. Typically, they view themselves as inadequate, weak, helpless, incompetent, and needy. They view others as strong, nurturing, supportive, and able to care for them.  TREATMENT Psychodynamic therapy for this pattern focuses on the transference of dependency needs onto the therapist. 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. On the cognitive end, the therapists also try to help the clients challenge and change their assumptions of incompetence and helplessness. Antidepressant drug therapy has been helpful for people whose personality disorder is accompanied by depression (Fava et al., 2002). 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. In addition, group members may serve as models for one another as they practice better ways to express feelings and solve problems.  Case Study Alan appeared to be well suited to his work as a train dispatcher. He was conscientious, perfectionistic, and attended to minute details. However, he was not close to his coworkers, and they reportedly thought him “off.” He would get quite upset if even minor variations to his daily routine occurred. For example, he would become tense and irritable if coworkers did not follow exactly his elaborately constructed schedules and plans. In short, Alan got little pleasure out of life and worried constantly about minor problems. His rigid routines were impossible to maintain, and he often developed tension headaches or stomachaches when he couldn’t keep his complicated plans in order. His physician, noting the frequency of his physical complaints and his generally perfectionistic approach to life, referred him for a psychological evaluation. Psychotherapy was recommended, but he did not follow up on the treatment recommendations because he felt that he could not afford the time away from work.  OBSESSIVE- COMPULSIVE PERSONALITY DISORDER Perfectionism and an excessive concern with maintaining order and control characterize individuals with obsessive-compulsive personality disorder (OCPD). These individuals are perfectionists and unyielding control freaks. They cannot rest until they get every detail exactly right. Because they insist that others can never be careful or competent enough, they never delegate or trust important matters to others. Their lives are controlled by schedules, rules, and rigid routines. Because of their scrupulous attention to details and their projects, they cannot relax, be spontaneous, or enjoy close and intimate relationships. They also tend to be devoted to work to the exclusion of leisure activities and may have difficulty relaxing or doing anything just for fun. According to surveys, as many as 7.9 percent of the adult population with a higher prevalence in males. People with OCD are more likely to be diagnosed with avoidant or dependent personality disorder than with OCPD.  An intriguing theory suggests that the psychological profiles of many serial killers point to the role of obsessive-compulsive personality disorder. Ferreira (2000) notes that these individuals do not often fit the definition of someone with a severe mental illness—such as schizophrenia—but are “masters of control” in manipulating their victims. Their need to control all aspects of the crime fits the pattern of people with obsessive- compulsive personality disorder, and some combination of this disorder and unfortunate childhood experiences may lead to this disturbing behavior pattern. Obsessive-compulsive personality disorder may also play a role among some sex offenders—in particular, pedophiles. Brain-imaging research on pedophiles suggests that brain functioning in these individuals is similar to those with obsessive-compulsive personality disorder (Schiffer et al., 2007). At the other end of the behavioral spectrum, it is also common to find obsessive-compulsive personality disorder among gifted children, whose quest for perfectionism can be quite debilitating  DSM 5 Criteria 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. 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). 5. Is unable to discard worn-out or worthless objects even when they have no sentimental value. 6. Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things. 7. Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes. 8. Shows rigidity and stubbornness  Etiology OCPD note that these individuals have excessively high levels of conscientiousness. This leads to extreme devotion to work, perfectionism, and excessive controlling behavior. They are also high on assertiveness (a facet of extraversion) and low on compliance (a facet of agreeableness). Another influential biological dimensional approach—that of Cloninger (1987)—posits three primary dimensions of personality: novelty seeking, reward dependence, and harm avoidance. Individuals with obsessive compulsive personalities have low levels of novelty seeking (i.e., they avoid change) and reward dependence (i.e., they work excessively at the expense of pleasurable pursuits) but high levels of harm avoidance (i.e., they respond strongly to aversive stimuli and try to avoid them). Recent research has also demonstrated that the OCPD traits show a modest genetic influence.  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. 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. 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.  Treatment 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.  QUESTIONS Match the following scenarios with the correct personality disorder. 1. During a therapy session John gets up for a glass of water. Ten minutes later John still is not back. He first had to clean the fountain area and neatly arrange the glasses before pouring his glass of water. 2. Whitney is self-critical and claims she is unintelligent and has no skills. She is also afraid to be alone and seeks constant reassurance from her family and friends. She says and does nothing about her cheating husband because she thinks that if she shows any resolve or initiative she will be abandoned and will have to take care of herself. 3. Mike has no social life because of his great fear of rejection. He disregards compliments and reacts excessively to criticism, which only feeds his pervasive feelings of inadequacy. Mike takes everything personally.