CHAPTER NINE
Personality Disorders
Personality Disorders
• What are Personality Disorders?
• Classification of Personality Disorders
Categorical vs. Dimensional models
• Features of Axis II
Implications for Assessment
• Specific Disorders:
Cluster A
Cluster B
Cluster C
Personality
• Most mental disorders are
defined in terms of states:
episodes of symptoms
• Personality refers to enduring
traits that are fairly stable over
time or make a person who
s/he is
What are Personality Disorders?
• Enduring patterns of
perceiving, relating to &
thinking about the
environment and oneself
– that are inflexible and
pervasive
– and cause either significant
functional impairment or
subjective distress
Categorical Classification of PDs (DSM)
• Advantages
 Familiar &
convenient
 Ease in
communication
 Consistent with
clinical diagnoses
Categorical Classification of PDs (DSM)
• Disadvantages
 low inter-rater reliability
 very high comorbidity
 high overlap among symptom criteria
 not based on a theoretical model
 ambiguity occurs regarding the
presence vs. absence of a PD
 most commonly diagnosed PD is PDNOS
Dimensional Model of Personality
• Looks at a continuum of normal to
abnormal personality
Personality
Disorder
– all individuals have some degree of
these traits, but those with PDs have
maladaptive levels
trait
• Various dimensional models exist
– Five Factor Dimensional Model
Normal
Traits
Five-Factor Model
• Neuroticism: expression of negative
emotions
• Extraversion: interest in interacting with
other people; positive emotions
• Openness: willingness to consider and
explore unfamiliar ideas, feelings, and
activities
• Agreeableness: willingness to
cooperate and empathize with others
• Conscientiousness: persistence in
pursuit of goals; organization;
dependability
Dimensional Model
• Advantages
 Theoretical basis
 Retention of information
• Leads to less stereotyping
• Adaptive traits are also highlighted
 Flexible
 Resolution of a variety of
classification dilemmas
• Avoids arbitrary assignment decisions
• Addresses problems with comorbidity in
the Categorical Model
• Higher inter-rater reliability
Dimensional Model
Disadvantages
 Less familiar
 Lacks clinical application
 May be too complex
 Disagreement exists about
preference of which dimensional
model to use
Features of Axis II
• Different etiology than Axis I
– not always true
• More stable than Axis I disorders
or more resistant to treatment
– however, some Axis I disorders are
very stable
– some PDs are treatable
Features of Axis II
• Other disorders: ego-dystonic
– personal distress, discomfort with
one’s symptoms
• Personality disorders: ego-syntonic
– ideas and impulses do not bother the
person
Assessment of PDs
• The ego-syntonic nature of
personality disorders can
make them difficult to assess
using traditional measures
• Others who have regular
contact with an individual
might be better judges of
how that person’s behavior
affects those around him/her
Culture and Personality
• Culture plays a large role in
determining what is appropriate or
acceptable at a given time and place
• Cultures may differ in:
 Degree of emotional
expression
 Individualism vs.
collectivism
Clusters of Personality Disorders
• Cluster A
 Paranoid PD
 Schizoid PD
 Schizotypal PD
• Cluster B
 Narcissistic PD
 Antisocial PD
 Histrionic PD
 Borderline PD
• Cluster C
 Avoidant PD
 Dependent PD
 Obsessive-Compulsive PD
Cluster A Personality Disorders
Characterized by odd,
eccentric, and/or socially
isolated behavior
 Paranoid PD
 Schizoid PD
Schizotypal PD
Paranoid Personality Disorder
• A pervasive distrust and suspiciousness of
others such that their motives are interpreted
as malevolent.
– Reluctant to confide in
others
– Hold grudges
– Finds threatening hidden
meaning in benign comments
– Doubt the loyalty and trustworthiness of others
• Requires 4 of the 7 possible criteria.
Paranoid Personality Disorder
• Prevalence rates: 0.5 to 2.5 %
• More common in men
• Unlikely to seek treatment
• Treatment –
• Trusting atmosphere
• Cognitive therapy to correct
cognitive errors
• Most therapists pessimistic
Schizoid Personality Disorder
• A pervasive pattern of detachment from social
relationships and a restricted range of
expression of emotions in interpersonal settings
- Doesn’t desire or enjoy close
relationships
- Prefers solitary activities and
takes pleasure in few things
- Is indifferent to praise and
criticism
• Requires 4 of the 7 possible criteria
Schizoid Personality Disorder
• Prevalence: < 1%
• More common in males
• Unlikely to seek
treatment
• Many therapists think
schizoid untreatable
Schizotypal Personality Disorder
• A pervasive pattern of interpersonal and
social deficits marked by acute discomfort
with, and reduced capacity for, close
relationships as well as by cognitive or
perceptual distortions and eccentricities of behavior
– Ideas of reference, magical thinking, and bodily
illusions
– Suspiciousness/paranoid thinking
– Inappropriate affect
– Lack of close friends/confidants
– Social anxiety
• Requires 5 of the 9 possible criteria
Schizotypal Personality Disorder
 Prevalence: 3-5%
 More common in males
Schizotypal PD and Schizophrenia
• Individuals with schizotypal PD:
– Sometimes have a history of psychological trauma,
especially childhood maltreatment
– Are at an increased risk of developing schizophrenia
– Are commonly relatives of
individuals with schizophrenia
• BUT…the vast majority of
individuals with Schizotypal PD
still do NOT have relatives with
schizophrenia
Individuals with
Schizotypal PD
People with
Schizophrenia
Cluster B Personality Disorders
Characterized by overly dramatic,
flamboyant, emotional, and/or
erratic behavior
 Narcissistic PD
 Antisocial PD
 Histrionic PD
 Borderline PD
Narcissistic Personality Disorder
• A pervasive pattern of
grandiosity, need for
admiration, and lack of
empathy
– Preoccupied with fantasies
– Associates only with high-status
others
– Has a strong sense of
entitlement
– Is interpersonally exploitative
– Is envious and thinks others are
envious of him/her
• Requires 5 of the 9 possible criteria
Narcissistic Personality Disorder
• Prevalence: 1%
• Link with poor parenting
• Treatment
• Little research
• Cognitive therapy to
improve empathy &
coping with criticism
• Vulnerable to depressive
episodes, may need
treatment for depression
Histrionic Personality Disorder
• A pervasive pattern of excessive emotionality
and attention seeking
– Inappropriately seductive/provocative
– Impressionistic style of speech
– Suggestible, easily influenced by others and
circumstances
– Considers relationships more intimate
than they really are
• Requires 5 of the 8 possible criteria
Histrionic Personality Disorder
• Prevalence: 2-3%
• More common in females
• Link with Antisocial PD?
• Treatment
• Behavior therapy and focus on
interpersonal relations
• Generally poor prognosis
Borderline Personality Disorder
• A pervasive pattern of instability of
interpersonal relationships, selfimage, and affects, and marked
impulsivity
–
–
–
–
Fears of abandonment
Suicidal gestures or self-mutilation
Chronic feelings of emptiness
Stress-related paranoid ideation or severe
dissociative symptoms
• Requires 5 of the 9 possible criteria
Borderline Personality Disorder
• Prevalence: 2%
• More common in females
• Link to ASPD
• Familial association w/
BPD & mood disorders
• Poor/abusive parenting
• Early trauma
• Challenges in treatment
Antisocial Personality Disorder
• A pervasive pattern of disregard for and violation
of the rights of others
–
–
–
–
–
Performing acts that are ground for arrest
Deceitfulness
Impulsivity
Consistent irresponsibility
Lack of remorse
• Requires:
– Age 18 or older
– Evidence of Conduct Disorder by age 15
Antisocial Personality Disorder
• Conduct Disorder  Antisocial  Prison
• Often comorbid with substance abuse
• Poor prognosis
• Prevalence: 3% in males, 1% in females
• May “burn out” after age 40
Psychopathy
• Deceptiveness or duplicity
• Absence of empathy,
compassion or remorse
toward the victims of the
psychopath's exploitative selfinterest.
• Can often be charming and
appear socially well-adjusted.
• May or may not engage in
criminal behavior.
Antisocial PD and Psychopathy
• Earlier conceptualizations of ASPD
had a greater overlap with
psychopathy
• However, due to DSM-IV’s focus
on observable behaviors, ASPD is
a distinct concept from
psychopathy (there is still some
overlap)
• Psychopathy is a better predictor
of recidivism than ASPD
Overlap between
ASPD, Psychopathy, & Criminality
20% of people with
ASPD are Psychopaths
ASPD
Psychopaths
Criminals
75-85% of criminals
have ASPD
15-25% of criminals
are Psychopaths
Overlap between
ASPD, Psychopathy, & Criminality
ASPD
Psychopaths
Criminals
Criminal Behavior
among Male Adoptees
50
Had biological
parents
without ASPD
40
30
20
Had biological
parents with
ASPD
10
0
In adoptive family with no
ASPD
In adoptive family with
ASPD
Social Factors & the Etiology of ASPD
• Inconsistent discipline (or complete
lack of discipline) often seen in the
prior family history of ASPD men
• Kids with a “difficult temperament” are
especially irritating to parents
• Parents respond inappropriately by
giving up or becoming severe in
punishment
• Person selects friends who share
antisocial interests and problems
(‘skinheads’, gangs)
Continuity in Life-Course-Persistent ASPD
• Person’s options become narrowed;
locked into further antisocial behavior
• Limited range of behavioral skills
(can’t pursue more appropriate
responses)
• Ensnared by consequences of earlier
behaviors
•
•
•
•
drug addiction
parenthood
school dropout
criminal record
Psychological Factors:
the Etiology of ASPD
• Avoidance learning in the lab
• Psychopaths unaffected by
anticipation of punishment
• Hypothesis 1: they can ignore
the effects of punishment
(emotional poverty)
• Hypothesis 2: they have trouble
shifting their attention
(impulsivity)
Cluster C Personality Disorders
Characterized by anxious
or avoidant behaviors
 Avoidant PD
 Dependent PD
 Obsessive-Compulsive PD
Avoidant Personality Disorder
• A pervasive pattern of social inhibition, feelings of
inadequacy, and hypersensitivity to negative
evaluation
- Avoids interpersonal job activities
- Won’t get involved with others
- Is preoccupied with criticism and
rejection
- Views self as socially inept,
personally unappealing, or inferior
to others
- Won’t try new things in case they
are embarrassing
• Requires 4 of the 7 possible criteria
Avoidant Personality Disorder
• Prevalence: < 1%
• May have biological
predisposition combined
with poor learning history
of early relationships
• Can be considered a
severe version of social
phobia, general type
Dependent Personality Disorder
• A pervasive and excessive need to be taken care
of that leads to submissive and clinging behavior
and fears of separation
– Has difficulty making everyday and
major decisions
– Won’t express disagreement
– Fails to initiate projects on own
– Feels uncomfortable or helpless
when alone
– Urgently seeks another relationship
when one ends
• Requires 5 of the 8 possible criteria
Dependent Personality Disorder
• Prevalence: 2% (no gender
difference)
• May be linked to early neglect &
disruptions in attachment
patterns
• Treatment -- little research, must
make sure client does not
become dependent on therapist!
Obsessive-Compulsive PD
• A pervasive pattern of preoccupation with
orderliness, perfectionism, and mental and
interpersonal control, at the expense of flexibility,
openness, and efficiency
– Preoccupied with rules, lists, details
– Neglects family/friends because of
devotion to work
– Is overconscientious about rules,
ethics, values
– Cannot discard worthless objects
– Hoards money in case of disaster
– Refuses to delegate tasks to others
• Requires 4 of the 8 possible criteria
Obsessive-Compulsive PD
• Prevalence: 1%
• More common in males
• Don’t confuse with OCD
• Some behaviors look similar
but OCD is ego-dystonic,
OCPD is ego-syntonic
• Treatment addresses
• Fears underlying need for order & control
• Distraction & relaxation techniques
Prevalence & Course: PD Summary
• PDs often originate in childhood &
become ingrained by adulthood
• Overall prevalence rate of 10-14%
• Course & prognosis depend on
disorder, but prognosis is
generally poor
Optional Slides
Five-Factor Model
• Neuroticism: expression of negative
emotions
• Extraversion: interest in interacting with
other people; positive emotions
• Openness: willingness to consider and
explore unfamiliar ideas, feelings, and
activities
• Agreeableness: willingness to
cooperate and empathize with others
• Conscientiousness: persistence in
pursuit of goals; organization;
dependability
Practice Example (kinda)
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Paranoid PD: Five Factor Profile
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Paranoid PD: Five Factor Profile
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Schizoid PD: Five Factor Profile
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Schizoid PD: Five Factor Profile
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Schizotypal PD: Five Factor Profile
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Schizotypal PD: Five Factor Profile
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Narcissistic PD: Five Factor Profile
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Narcissistic PD: Five Factor Profile
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Histrionic PD: Five Factor Profile
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Histrionic PD: Five Factor Profile
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Borderline PD: Five Factor Profile
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Borderline PD: Five Factor Profile
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Antisocial PD: Five Factor Profile
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Antisocial PD: Five Factor Profile
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Avoidant PD: Five Factor Profile
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Avoidant PD: Five Factor Profile
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Dependent PD: Five Factor Profile
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Dependent PD: Five Factor Profile
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OCPD: Five Factor Profile
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OCPD: Five Factor Profile
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Why care about PDs?
• PDs are associated with significant
impairment (e.g., social impairment)
• Presence of pathological personality
traits as an adolescent is associated
with increased risk for the later
development of other mental
disorders
• Sometimes, PDs represent the
beginning stages of the onset of a
more serious disorder
How do we describe PDs?
• Axis II — chronic and long term
• Tend to irritate people around
them
• Difficult to maintain personal
relationships
Peer Nomination
• Done with groups of individuals
• Members of a group are asked to
name individuals in the group who
have high levels of a particular trait
• Studies have found that informants
are more willing to identify the
negative aspects of personality than
individuals are to self-report them
Paranoid Personality Disorder
• S stubborn, sarcastic, hostile
• U unforgiving - bears grudges
• S suspicious (of others)
• P perceives attacks (reacts quickly)
• E enemy in everyone (suspects all)
• C confiding in others is feared
• T threats seen in benign events
Schizoid Personality Disorder
•
•
•
•
•
•
S
O
L
I
T
A
shows emotional coldness
omits close relationships
lacks close friends or confidants
involved in solitary activities
takes pleasure in few activities
appears indifferent to praise or
criticism
• R restricted interest in sexual
experiences
• Y yanks himself or herself from
social relationships
Schizotypal Personality Disorder
• M magical thinking, superstitious, paranormal
• E eccentric behavior or appearance
•
•
•
•
•
•
•
•
P
E
C
U
L
I
A
R
paranoid ideation (suspicious)
experiences unusual perceptions
constricted affect
unusual thinking & speech
lacks friends
ideas of reference
anxiety (socially)
rule out psychotic disorders & PDD
Narcissistic Personality Disorder
•
•
•
•
•
•
W
O
R
S
H
I
• P
wants special treatment from others
overestimates abilities, boastful
requires excessive admiration
strong sense of entitlement
has grandiose sense of self-importance
insists on only being affiliated with
important people and institutions
preoccupied with fantasies of
brilliance, beauty or ideal love
• M Machiavellian attitude
• E envious of others
Histrionic Personality Disorder
• P provocative or seductive behavior
• R relationships, considered more
intimate than they are
• A attention (must be the center of)
• I influenced easily
• S speech style – impressionistic
• E emotional lability, shallowness
• M make-up, draws attention to self
• E exaggerated emotions, theatrical
Borderline Personality Disorder
• P paranoid ideas
• R relationship instability
• A angry outbursts, abandonment
fears, affective instability
• I impulsive behavior, identity
disturbance
• S suicidal behavior
• E emptiness
Antisocial Personality Disorder
• C cannot follow law
• O obligations ignored
• R remorselessness
• R recklessness
• U underhandedness (deceitful)
• P planning deficit
• T temper
Avoidant Personality Disorder
• A avoids occupational activities
• V views self as socially inept
• O occupied with being criticized or
rejected (insecure)
• I inhibited in new interpersonal
situations (afraid around others)
• D denies involvement with people
• E embarrassed by engaging in new
activities
• R reluctant to get involved in intimate
relationships
Dependent Personality Disorder
• D difficulty making everyday decisions
• E excessive lengths to obtain nurturance
• P preoccupied with fears of being left to
• E
• N
• D
• E
• N
• T
take care
exaggerated fears of being unable to
care for himself or herself
needs others to assume responsibility
difficulty expressing disagreement
end of one relationship is the
beginning of another relationship
noticeable difficulties in initiating
projects (low self-confidence)
“take care of me” is his or her motto
Obsessive-Compulsive PD
• P preoccupation with details, rules,
order, organization or schedules
• E excessive devotion to work and
productivity
• R reluctance to work with others
unless they give up complete control
• F frugal (miserly spending style toward
both self and others)
• E excessive rigidity and stubbornness
• C concentrate on details; completion of
tasks is problematic
• T time is poorly allocated
Schizotypal PD and Schizophrenia
• The vast majority of individuals with
schizotypal PD do not have relatives
with schizophrenia
• Schizotypal PD associated with
history of psychological trauma,
especially childhood maltreatment
(this is not true for schizophrenia)
• There may be two distinct pathways
to schizotypal PD
– genes associated with schizophrenia
– psychological trauma
Individuals with
Schizotypal PD
People with
Schizophrenia
Continuity: Life-Course-Persistent
AGE
PRESCHOOL
ADOLESCENCE
(Loeber, 1990)
Developmental Stacking
Loeber, 1990
DELINQUENCY
PEER PROBLEM
POOR SOCIAL SKILLS
AGGRESSIVE BEHAVIORS
OPPOSITIONAL PROBLEMS
HYPERACTIVITY
BRAIN DAMAGE
MOTHER’S
DRUG USE
TIME
According to your book, the enduring deviant
patterns of experience and behavior that mark PDs
must be present in how many domains?
•
•
•
•
•
A. 1
B. 2
C. 3
D. 4
E. 5
Correct Answer = B
What are some of these domains?
In what area of functioning to do we often see the
greatest impairment in PDs? What about PDs makes
this impairment so important to consider?
What is another name sometimes given to Cluster A
PDs?
•
•
•
•
•
A. Dramatic, Emotionally Unstable Disorders
B. Anxious, Avoidant Disorders
C. Bizarre, Mistrusting Disorders
D. Schizophrenia Spectrum Disorders
E. Bizarre Spectrum Disorders
Correct Answer = D
Why is this alternative name reasonable for Cluster A PDs?
In what ways are each of the Cluster A PDs similar to
Schizophrenia? In what ways are they distinct from each
other?
One of these things is not like the others…
Which of the following would not be seen in Paranoid PD?
•
•
•
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•
A. pervasive mistrust of others
B. strong desire for autonomy
C. finding pleasure in few activities
D. an inability to forgive others
E. hostility
Correct Answer = C
Which Cluster A PD is characterized by finding little
pleasure in activities?
One of these things is not like the others…
Which of the following would not be seen in Narcissistic PD?
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A. dramatic attention-seeking behaviors
B. presenting a grandiose self-concept
C. lack of empathy
D. upward comparisons to famous people
E. disappointment in response to a lack of
praise
Correct Answer = A
In which Cluster B PD do we usually see dramatic
attention-seeking behaviors?
Why is it important that, in option B, I wrote “presenting
a grandiose self-concept?
One of these things is not like the others…
Which of the following would not be found in Borderline PD?
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A. identity disturbance/unstable self-concept
B. fears of abandonment
C. lack of remorse
D. parasuicidal behaviors
E. short-lived dissociative symptoms
Correct Answer = C
What are parasuicidal behaviors? How are these
behaviors hypothesized to be connected to
dissociative symptoms in BPD?
Which of the following is not a benefit of the
dimensional approach to classifying PDs?
• A. it enables us to be more strengths-focused in our
treatment
• B. it makes it easier to discuss personality issues with
clients
• C. it has a better theoretical and empirical basis than
the current categories
• D. it has higher inter-rater reliability
• E. it is very familiar to most practicing clinicians
Correct Answer = E
What are some of the other disadvantages of the dimensional approach?
What are the advantages and disadvantages of the categorical approach?
Is APD redundant with Generalized Social Phobia?
• Social Phobia  Generalized Social Phobia  APD
• Who tends to suggest that APD is unnecessary?
• What do they suggest should be done with the APD
category?
– Are these fair or reasonable suggestions?
• What is it that most psychologists don’t know?
– Why aren’t they aware of this information?
The dimensions of DPD
• Previous research suggests that DPD is
actually bidimensional
– Dependence/Incompetence
– Dysfunctional or Insecure Attachment
• Different relationships to other PDs
• Implications
– Necessity of different treatment approaches
– More evidence of comorbidity and symptom
overlap problems
Do Cluster C PDs belong together?
• The research and clinical opinions are a bit
mixed.
– OCPD is sometimes separate
– DPD is bidimensional
– There is evidence of a common latent trait
• Seems to center around issues with criticism
• Research on how these disorders both do
and do not overlap is still sorely needed
Special Topic
Understanding
Psychopathy
Psychopaths vs. Sociopaths
Paranoid Personality Disorder
 Pervasive, extreme
mistrust
 Often hostile
 Suspicious and perceive
others’ motives as
malevolent
 Familial association with
Delusional Disorder
Schizoid Personality Disorder
Aloof, cold
Detached from social
relations
Restricted experience
or range of emotion
Not distressed by lack
of social contact
Schiztypal Personality Disorder
 Behavioral eccentricities
 Cognitive or perceptual
distortions
 Ideas of reference
 Magical thinking
 Illusions
 Discomfort with close
relationships
Narcissistic Personality Disorder
 Grandiose
 Self-absorbed
 Lack empathy
 Need admiration
 Exploit others
 Envious, arrogant
 Sensitive to criticism
Histrionic Personality Disorder
• Excessive emotionality
• Need to be center of
attention
• Provocative
• Dramatic
Borderline Personality Disorder
• Fear of abandonment
• Unstable interpersonal
relations
• Unstable self-image or
identity
• Chronic feelings of
emptiness
• Affective instability or
reactivity of mood
Borderline Personality Disorder
• Impulsive
• Inappropriate and intense
anger
• Transient, stress-related
dissociative symptoms
• Self-mutilation and
suicidal gestures
Antisocial Personality Disorder
 Persistent violation of
others’ rights
 Impulsive
 Deceitful
 Lack of remorse
 Difficulty learning lessons
 Must be 18
Avoidant Personality Disorder
 Fear of negative
evaluation
 Feelings of inadequacy
 Social inhibition and
interpersonal avoidance
 Want contact with others
but are afraid of criticism
Dependent Personality Disorder
Excessive need to be
cared for
Submissive
Clinging
Fears of separation
Overly eager to please
(responds to criticism by
clinging)
Obsessive-Compulsive PD
Preoccupied with:
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Details
Orderliness
Perfectionism
Control
Excessively devoted to
work
Inflexible
• Often interferes with task
completion