Cluster C

Patients diagnosed with any of the Cluster C PDs have the best outcomes for therapy, particularly when compared to individuals with Cluster A or Cluster B disorders (Magnavita, 1997). Typically, patients with Cluster C disorders experience high levels of anxiety and fear, and have difficulty expressing emotions. Based upon this premise, patients in this cluster experience more impairment as they seek treatment services to fix Axis I disorders, such as depression and anxiety; therefore, patients in this cluster are more motivated to change behaviors, feelings, and cognitions to relieve symptom distress (Magnavita, 1997).

Avoidant PD

Depression co-occurring with avoidant PD (APD) is very common, because avoidant persons isolate themselves as means of protecting their well-being, yet desire human interaction (Millon & Davis, 2000). Avoidant individuals are different than Cluster A personalities, in that they desire human interaction, but fear potential rejection, embarrassment, criticism and subsequent depression. Oftentimes, these fears make the avoidant appear introverted or shy. The push-pull effect of pushing people away, but then wishing for their company can take a toll on the avoidant's life. Depression symptoms manifest in the patient's self-imposed social, cognitive, and emotional isolation. Eventually, depressive symptoms are generated and presented as full-blown depressive episodes or as low-level, but enduring patterns of depression (Beck et al., 2004; Millon & Davis, 2000).

Robin, age 27, came to treatment with her self-diagnosed problems of avoidant personality, dependent personality, social anxiety, and major depression—all diagnoses she obtained from various websites. At one website for avoidant/social anxiety disorders, a person in the chatroom "guaranteed" that these were Robin's disorders. Robin had been in psychotherapy for several years for the treatment of her anxiety. What emerged rather quickly in the current therapy was that Robin was far more narcissistic than anxious, and that being in the center of everyone's radar was her major goal. The more anxious she was, the more attentive her husband, parents, friends, and coworkers, all of whom she had previously alerted to her needs.

Dependent PD

There is overwhelming evidence that patients diagnosed with dependent PD (DPD) often have comorbid depression. In fact, most research attempts to determine whether depression can be distinguished as separate from DPD (Beck et al., 2003; Millon, 2000). Depressive issues generally center on perceived hopelessness and helplessness, thereby contributing to the difficulty of treating this particular population. Usually patients with DPD have negative reactions to normal adverse situations contributing to the therapeutic difficulties. Poor motivation and lack of coping skills tend to complicate the treatment process; causing the patient to be more dependent on outside resources and to feel less competent.

Sally, age 38, came to therapy because she was overwhelmed by her work. A first-grade teacher, she was "weeks behind" on grading student test papers. Sally reported that her dining room table was covered with these spelling and arithmetic tests. When asked why she had so much trouble in grading papers, Sally reported that she could not use an answer key; therefore, she graded each question on each paper individually. When asked why she could not use an answer key, Sally stated that if there was a misprint on a single test paper and she used an answer key, she would be in danger of grading a correct answer as incorrect, and the student would "suffer" a lower grade. Sally reported that one of her childhood fantasies was that while she was in the bath tub a shark would come out of the drain and devour her. Sally could bathe only if her mother sat in the bathroom. This continued until Sally was 12 years old.

Obsessive-Compulsive PD

Depression is often a co-occurring disorder among patients diagnosed with obsessive-compulsive PD (OCPD) (Millon & Davis, 2000). The general pessimistic and negative attitudes about self, others, and life that contribute to issues of depression suggest that perhaps this is a lifestyle choice. For instance, some patients with OCPD use depression as a form of self-punishment, perpetuating the cycle of obsessive-compulsive behaviors. The depression maintains their need to engage cognitively, behaviorally, and emotionally in obsessive-compulsive rituals to find ultimate relief that, consequentially, is never fully achieved. Thus, patients continue the perpetual cycle of attempting to find relief, like a dog chasing its tail. The earlier case of Sally illustrates quite clearly both DPD and OCPD.

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