Personality Disorders
Personality Disorders Overview
Personality disorders are characterized by a persistent pattern of emotions, cognitions, and behavior that cause enduring emotional distress for the affected individual and/or others, potentially leading to difficulties in work and relationships.
High comorbidity is often observed among personality disorders.
They typically have a poorer prognosis compared to other mental disorders.
Therapist reactions, including countertransference, can occur when working with individuals with personality disorders.
There are 10 specific personality disorders recognized, which are organized into 3 clusters.
Categorical and Dimensional Models
Categorical vs. dimensional models represent different approaches to understanding personality disorders.
Categorical models classify individuals into distinct categories or types.
Dimensional models, on the other hand, view personality traits as existing on a continuum.
The distinction between "Kind" vs. "Degree" highlights the difference between categorical and dimensional models.
Dimensional models emphasize dimensions instead of categories.
In a dimensional model, individuals receive categorical diagnoses and are rated on personality dimensions.
The "Emerging measures and models" reflects the ongoing evolution of diagnostic approaches.
Five-Factor Model of Personality ("Big Five")
The Five-Factor Model of personality, also known as the "Big Five", is a dimensional model that describes personality traits along five broad dimensions:
Openness to experience
Conscientiousness
Extraversion
Agreeableness
Emotional stability
Cross-cultural research supports the universal nature of these five dimensions.
Personality Disorder Clusters
Personality disorders are grouped into three clusters (A, B, and C) based on descriptive similarities.
Cluster A: Odd or Eccentric Disorders
Characterized by odd or eccentric behaviors.
Includes paranoid, schizoid, and schizotypal personality disorders.
Cluster B: Dramatic, Emotional, Erratic Disorders
Characterized by dramatic, emotional, or erratic behaviors.
Includes antisocial, borderline, histrionic, and narcissistic personality disorders.
Cluster C: Fearful or Anxious Disorders
Characterized by fearful or anxious behaviors.
Includes avoidant, dependent, and obsessive-compulsive personality disorders.
Table 12.1: Personality Disorders
Cluster A - Odd or Eccentric Disorders
Paranoid personality disorder: A pervasive distrust and suspiciousness of others, interpreting their motives as malevolent.
Schizoid personality disorder: A pervasive pattern of detachment from social relationships and a restricted range of emotional expression in interpersonal settings.
Schizotypal personality disorder: A pervasive pattern of social and interpersonal deficits marked by acute discomfort with reduced capacity for close relationships, cognitive or perceptual distortions, and eccentricities of behavior.
Cluster B - Dramatic, Emotional, or Erratic Disorders
Antisocial personality disorder: A pervasive pattern of disregard for and violation of the rights of others.
Borderline personality disorder: A pervasive pattern of instability of interpersonal relationships, self-image, affects, and control over impulses.
Histrionic personality disorder: A pervasive pattern of excessive emotion and attention seeking.
Narcissistic personality disorder: A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy.
Cluster C - Anxious or Fearful Disorders
Avoidant personality disorder: A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.
Dependent personality disorder: A pervasive and excessive need to be taken care of, leading to submissive and clinging behavior and fears of separation.
Obsessive-compulsive personality disorder: A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency.
Statistics and Development
The prevalence of personality disorders is estimated to be around 6%, but may be closer to 10%.
Origins and course:
Personality disorders typically begin in childhood.
They often have a chronic course.
In some cases, one personality disorder may remit, but be replaced by another.
High comorbidity is common among personality disorders and with other mental disorders.
Statistics and Development of Specific Personality Disorders (Table 12.2)
Paranoid Personality Disorder
Prevalence: Insufficient information.
Gender Differences: Approximately equal among men and women.
Course: Chronic; some may develop schizophrenia.
Schizoid Personality Disorder
Prevalence: Clinical population: 1.4%-1.9%; General population: 0.9%-1.2%.
Gender Differences: Slightly more common among men.
Course: Insufficient information.
Schizotypal Personality Disorder
Prevalence: Clinical population: 6.4%-5.7%; General population: 0.7%-1.1%.
Gender Differences: Slightly more common among men.
Course: Chronic; some may develop schizophrenia.
Antisocial Personality Disorder
Prevalence: Clinical population: 3.9%-5.9%; General population: 1.0%-1.8%.
Gender Differences: Much more common among men.
Course: Dissipates after age 40.
Borderline Personality Disorder
Prevalence: Clinical population: 28.5%; General population: 1.4%-1.6%.
Gender Differences: Approximately equal among men and women.
Course: Symptoms gradually improve if individuals survive into their 30s; approximately 6% die by suicide.
Histrionic Personality Disorder
Prevalence: Clinical population: 8.0%-9.7%; General population: 1.2%-1.3%.
Gender Differences: Slightly more common among women.
Course: Chronic.
Narcissistic Personality Disorder
Prevalence: Clinical population: 5.1%-10.1%; General population: 0.1%-0.8%.
Gender Differences: Slightly more common among men.
Course: May improve over time.
Avoidant Personality Disorder
Prevalence: Clinical population: 21.5%-24.6%; General population: 1.4%-2.5%.
Gender Differences: Slightly more common among women.
Course: Insufficient information.
Dependent Personality Disorder
Prevalence: Clinical population: 13.0%-15.0%; General population: 0.9%-1.0%.
Gender Differences: Much more common among women.
Course: Insufficient information.
Obsessive-Compulsive Personality Disorder
Prevalence: Clinical population: 6.1%-10.5%; General population: 1.9%-2.1%.
Gender Differences: Slightly more common among men.
Course: Insufficient information.
Gender Differences
Men diagnosed with a personality disorder tend to display traits characterized as more:
Aggressive, structured, self-assertive and detached
Women tend to present with characteristics that are:
More submissive, emotional and insecure
Gender Differences: Potential Biases
Clinician bias may influence diagnoses.
Assessment bias in the tools used to evaluate personality disorders.
Criterion gender bias: Some disorders may be defined in ways that align with gender stereotypes.
Histrionic personality disorder may exemplify extreme "stereotypical female" traits.
The absence of a "macho" disorder.
Ford and Widiger (1889) investigated gender bias in personality disorder diagnoses.
Comorbidity
Comorbidity is common, with approximately 10% of individuals having multiple personality disorders.
Personality Disorders Under Study
Sadistic personality disorder
Passive-aggressive personality disorder
Table 12.3: Diagnostic Criteria for "Independent" (Example)
Puts work (career) above relationships with loved ones (e.g., travels a lot for business, works late at night and on weekends).
Is reluctant to consider others' needs when making decisions, especially concerning career or leisure time (e.g., expects spouse and children to relocate due to individual's career plans).
Passively allows others to assume responsibility for major areas of social life because of inability to express necessary emotion (e.g., lets spouse assume most childcare responsibilities).
Table 12.4: Diagnostic Overlap of Personality Disorders
The table presents odds ratios indicating the likelihood of co-occurrence of different personality disorders.
An odds ratio greater than 1 suggests a higher likelihood of the two disorders co-occurring.
Odds ratios with an asterisk (*) indicate statistically significant associations.
Table 12.5: Main Beliefs Associated with Specific Personality Disorders
Paranoid: I cannot trust people.
Schizotypal: It's better to be isolated from others.
Schizoid: Relationships are messy, undesirable.
Histrionic: People are there to serve or admire me.
Narcissistic: Since I am special, I deserve special rules.
Borderline: I deserve to be punished.
Antisocial: I am entitled to break rules.
Avoidant: If people knew the "real" me, they will reject me.
Dependent: I need people to survive, be happy.
Obsessive-Compulsive: People should do better, try harder.
Cluster A: Paranoid Personality Disorder
Clinical description:
Mistrust and suspicion of others.
Pervasive and unjustified.
Few meaningful relationships.
Volatile and tense.
Sensitive to criticism.
Cluster A: Paranoid Personality Disorder: Causes
Possible relationship to schizophrenia.
Possible role of early experience:
Trauma
Learning: Belief that people are malevolent and deceptive.
Cultural factors: Higher prevalence in prisoners, refugees, people with hearing impairments, and older adults.
Cluster A: Paranoid Personality Disorder: Treatment
Individuals are unlikely to seek treatment on their own, unless in crisis.
Focus on developing trust in therapy.
Cognitive therapy to address maladaptive assumptions.
No empirically-supported treatments with demonstrated efficacy.
Poor improvement rate.
Cluster A: Paranoid: DSM-5 Diagnostic Criteria
A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her.
Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.
Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her.
Reads hidden demeaning or threatening meanings into benign remarks or events.
Persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights.
Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack.
Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.
B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiological effects of another medical condition.
Note: If criteria are met prior to the onset of schizophrenia, add "premorbid," i.e., "paranoid personality disorder (premorbid)."
Cluster A: Schizoid Personality Disorder
Clinical description:
Appear to neither enjoy nor desire relationships.
Loner.
Limited range of emotions.
Appear cold, detached.
Appear unaffected by praise or criticism.
Unable or unwilling to express emotion.
No thought disorder.
Cluster A: Schizoid Personality Disorder: Causes
Limited research.
Possible precursor: childhood shyness.
Possibly related to:
Abuse/neglect
Autism
Cluster A: Schizoid Personality Disorder: Treatment
Unlikely to seek treatment on own, unless in crisis.
Focus on relationships.
Social skills therapy.
Empathy training.
Role playing.
Social network building.
Empirically-supported treatments are limited.
Cluster A: Schizoid: Grouping Schema (Table 12.6)
Paranoid: Yes (Psychotic-Like Symptoms - Positive), Yes (Psychotic-Like Symptoms - Negative)
Schizoid: No (Psychotic-Like Symptoms - Positive), Yes (Psychotic-Like Symptoms - Negative)
Schizotypal: Yes (Psychotic-Like Symptoms - Positive), No (Psychotic-Like Symptoms - Negative)
Cluster A: Schizoid: DSM-5 Diagnostic Criteria
A. A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
Neither desires nor enjoys close relationships, including being part of a family.
Almost always chooses solitary activities.
Has little, if any, interest in having sexual experiences with another person.
Takes pleasure in few, if any, activities.
Lacks close friends or confidants other than first-degree relatives.
Appears indifferent to the praise or criticism of others.
Shows emotional coldness, detachment, or flattened affectivity.
B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder and is not attributable to the physiological effects of another medical condition.
Note: If criteria are met prior to the onset of schizophrenia, add "premorbid," e.g., "schizoid personality disorder (premorbid)."
Cluster A: Schizotypal Personality Disorder
Clinical description:
Psychotic-like symptoms:
Magical thinking
Ideas of reference
Illusions
Odd and/or unusual:
Behavior
Appearance
Socially isolated
Suspicious
Cluster A: Schizotypal Personality Disorder: Causes
Schizophrenia phenotype?
Lacking full biological or environmental contributions.
Cognitive impairments:
Left hemisphere
More generalized.
Cluster A: Schizotypal Personality Disorder: Treatment
Treatment of comorbid depression (30-50%).
Multidimensional approach:
Social skill training
Antipsychotic medications
Community treatment
Cluster A: Schizotypal: DSM-5 Diagnostic Criteria
A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships, as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
Ideas of reference (excluding delusions of reference).
Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or "sixth sense"; in children and adolescents, bizarre fantasies or preoccupations).
Unusual perceptual experiences, including bodily illusions.
Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped).
Suspiciousness or paranoid ideation.
Inappropriate or constricted affect.
Behavior or appearance that is odd, eccentric, or peculiar.
Lack of close friends or confidants other than first-degree relatives.
Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.
B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder.
Note: If criteria are met prior to the onset of schizophrenia, add "premorbid," e.g., "schizoid personality disorder (premorbid)."
Cluster B: Antisocial Personality Disorder
Clinical description:
Noncompliance with social norms.
"Social Predators".
Violate rights of others.
Irresponsible.
Impulsive.
Deceitful.
Lack a conscience, empathy, and remorse.
Cluster B: Antisocial: Nature of Psychopathy
Glibness/superficial charm
Grandiose sense of self-worth
Pathological lying
Conning/manipulative
Lack of remorse
Callous/lack of empathy
Cluster B: Antisocial: More Trait-Based Approach
Overlap with ASPD, criminality
Intelligence
Cluster B: Antisocial: Developmental Considerations
Early histories of behavioral problems:
Conduct disorder
Childhood-onset type
Adolescent-onset type
Families history of:
Inconsistent parental discipline
Variable support
Criminality
Violence
Cluster B: Antisocial: DSM-5 Diagnostic Criteria
A. A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by three (or more) of the following:
Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.
Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.
Impulsivity or failure to plan ahead.
Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
Reckless disregard for safety of self or others.
Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.
Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.
B. The individual is at least age 18 years.
C. There is evidence of conduct disorder with onset before age 15 years.
D. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder.
Causes of Antisocial Personality Disorder
Gene-environment interaction:
Genetic predisposition
Environmental triggers
Arousal hypotheses:
Underarousal
Fearlessness
Causes of Antisocial Personality Disorder: Gray’s Model of Brain Functioning
Behavioral inhibition system (BIS): Low
Reward system: High
Fight/flight system
Causes of Antisocial Personality Disorder: Interactive, Integrative Model
Genetic vulnerability
Neurotransmitters
Environmental factors
Family stress and dysfunction
Reinforcement of antisocial behaviors
Alienation from good role models
Poor occupational/social function
Antisocial Personality Disorder: Treatment
Unlikely to seek treatment on own.
High recidivism.
Incarceration.
Early intervention & Prevention:
Parent training
Rewards for pro-social behaviors
Skills training
Improve social competence
Cluster B: Borderline Personality Disorder
Clinical description:
1-2% of population.
Patterns of instability:
Intense moods
Turbulent relationships
Impulsivity
Very poor self-image
Self-mutilation
Suicidal gestures
Cluster B: Borderline: DSM-5 Diagnostic Criteria
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
Identity disturbance: markedly and persistently unstable self-image or sense of self.
Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self-mutilating behavior covered in criterion 5.)
Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
Chronic feelings of emptiness.
Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
Transient, stress-related paranoid ideation or severe dissociative symptoms.
Cluster B: Borderline: Comorbid Disorders
Depression – 20%
Suicide – 6%
Bipolar – 40%
Substance abuse – 67%
Eating disorders
25% of bulimics have BPD
Cluster B: Borderline: Causes
Genetic/biological components:
Serotonin
Limbic network
Cognitive biases
Early childhood experience:
Neglect
Trauma
Abuse
An Integrative Model
Cluster B: Borderline: Treatment
Highly likely to seek treatment
Antidepressant medications
Dialectical behavior therapy (DBT):
Reduce "interfering" behaviors:
Self-harm
Treatment
Quality of life
Outcomes
Cluster B: Histrionic Personality Disorder
Clinical description:
Center of attention
Sexually provocative
Shallow shifting emotions
Physical appearance-focused
Impressionistic
Overly dramatic
Suggestible
Misinterprets relationships
Cluster B: Histrionic: DSM-5 Diagnostic Criteria
A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
Is uncomfortable in situations in which he or she is not the center of attention.
Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.
Displays rapidly shifting and shallow expression of emotions.
Consistently uses physical appearance to draw attention to self.
Has a style of speech that is excessively impressionistic and lacking in detail.
Shows self-dramatization, theatricality, and exaggerated expression of emotion.
Is suggestible (i.e., easily influenced by others or circumstances).
Considers relationships to be more intimate than they actually are.
Cluster B: Histrionic: Causes
Little research
Links with antisocial personality
Sex-typed alternative expression
Cluster B: Histrionic: Treatment
Problematic interpersonal relationships:
Attention seeking
Long-term consequences of behavior
Little empirical support
Cluster B: Narcissistic Personality Disorder
Clinical description:
Exaggerated and unreasonable sense of self-importance.
Grandiosity.
Require attention.
Lack sensitivity and compassion.
Sensitive to criticism.
Envious.
Arrogant.
Cluster B: Narcissistic: DSM-5 Diagnostic Criteria
A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
Believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
Requests excessive admiration.
Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations).
Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends).
Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
Is often envious of others or believes that others are envious of him or her.
Shows arrogant, haughty behaviors or attitudes.
Cluster B: Narcissistic: Causes
Deficits in early childhood learning:
Altruism
Empathy
Sociological view:
Increased individual focus
"Me generation"
Cluster B: Narcissistic: Treatment
Treatment focuses on:
Grandiosity
Lack of empathy
Hypersensitivity to evaluation
Co-occurring depression
Little empirical support
Cluster C: Avoidant Personality Disorder
Clinical description:
Extreme sensitivity to opinions.
Avoid most relationships.
Interpersonally anxious.
Fearful of rejection.
Cluster C: Avoidant: DSM-5 Diagnostic 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:
Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection.
Is unwilling to get involved with people unless certain of being liked.
Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.
Is preoccupied with being criticized or rejected in social situations.
Is inhibited in new interpersonal situations because of feelings of inadequacy.
Views self as socially inept, personally unappealing, or inferior to others.
Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.
Cluster C: Avoidant: Causes
Schizophrenia-related disorders
Difficult temperament
Early parental rejection
Interpersonal isolation and conflict
Cluster C: Avoidant: Treatment
Similar to social phobia
Increase social skills
Therapeutic alliance
Moderate empirical support
Cluster C: Dependent Personality Disorder
Clinical description:
Rely on others for major and minor decisions
Unreasonable fear of abandonment
Clingy
Submissive
Timid
Passive
Feelings of inadequacy
Sensitivity to criticism
High need for reassurance
Cluster C: Dependent: DSM-5 Diagnostic 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:
Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.
Needs others to assume responsibility for most major areas of his or her life.
Has difficulty expressing disagreement with others because of fear of loss of support or approval. (Note: Do not include realistic fears of retribution.)
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).
Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant.
Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care of himself or herself.
Urgently seeks another relationship as a source of care and support when a close relationship ends.
Is unrealistically preoccupied with fears of being left to take care of himself or herself.
Cluster C: Dependent: Causes
Little research
Early experience
Death of a parent
Rejection by caregiver
Attachment
Genetic influences
Cluster C: Dependent: Treatment
Limited empirical support
Caution: dependence on therapist
Gradual increases in:
Independence
Personal responsibility
Confidence
Cluster C: Obsessive-Compulsive Personality Disorder
Clinical description:
Fixation on doing things the “right way”
Rigid
Perfectionistic
Orderly
Preoccupation with details
Poor interpersonal relationships
Obsessions and compulsions are rare
Cluster C: Obsessive-Compulsive: DSM-5 Diagnostic 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:
Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost.
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).
Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity).
Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification).
Is unable to discard worn-out or worthless objects even when they have no sentimental value.
Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things.
Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes.
Shows rigidity and stubbornness.
Cluster C: Obsessive-Compulsive: Causes
Limited research
Weak genetic contributions
Predisposed to favor structure?
Cluster C: Obsessive-Compulsive: Treatment
Similar to OCD
Address fears related to the need for orderliness
Limited efficacy data