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Cluster C Anxious-Fearful Personality Pathology and Avoidance

Charles A. Sanislow and Anna Darre Hector

Introduction

Cluster C of the DSM-5 (APA, 2013), known as the anxious-fearful group of personality disorders, consists of the diagnoses Avoidant Personality Disorder (AVPD), Dependent Personality Disorder (DPD), and Obsessive-Compulsive Personality Disorder (OCPD). When the cluster groupings were first introduced in the DSM-III (APA, 1980), there was a fourth diagnosis, Passive Aggressive Personality Disorder (PAPD), which was retained in the DSM-III-R (APA, 1987), relegated to research status in the DSM fourth editions with the subtitle Negativistic Personality Disorder (APA, 1994, 2000), and then dropped in the DSM-5 (APA, 2013). To describe the core characteristics of anxious-fearful psychopathology, features of the DSM-5 Section II diagnoses, Passive Aggressive Personality Disorder (PAPD), and the Alternative Model of Personality Disorders (AMPD) in Section III of the DSM-5 are considered, with an emphasis on avoidant behavior.

The first section of this chapter describes the AVPD and related Cluster C personality diagnoses as set forth in Section II of DSM-5 (APA, 2013). We also discuss anxious-fearful personality pathology as conceptualized in the Alternative Model of Personality Disorders (AMPD; APA, 2013). The background and development of these definitions are considered to provide historical context for how the prototype of this kind of psychopathology has been understood, especially how associated features/symptoms have been lumped and split. This broader vision for how characterological anxious-fearful distress has been defined should provide perspective for future directions. Questions are raised concerning stability continuities and comorbidities, within-disorder heterogeneity, and ways that Cluster C diagnoses relate to clinical (non-personality) disorders and to avoidant behaviors. These questions prompt consideration of cross-cutting (i.e., transdiagnostic) dimensions, including trait-based constructs, along with well-studied constructs such as rejection sensitivity, perfectionism, dependency, shame and guilt. Additionally, alternative research approaches such as the National Institute of Mental Health (NIMH) Research Domain Criteria (RDoC) may be helpful in clarifying internal mechanisms of anxious-fearful psychopathology. We conclude with some thoughts about future directions, including some new ideas about how to represent personality disorders, traits, and mechanisms in the context of interpersonal relationships.

It is both an interesting and exciting time to be writing about DSM personality disorders. It is interesting because the field of psychopathology is in a state of flux, and definitions are more like targets under development than static, natural kinds. To illustrate, despite the substantial effort that went into a major revision of the characterization of the personality disorders for the most recent, fifth edition of the DSM (APA, 2013), the updated diagnostic structure for personality disorders reflects remaining disagreement about the best diagnostic structure. It is an exciting time because dialogue in the literature can stimulate novel ways to think of where to go next. Other chapters in this volume address questions about revisions and evidence for competing models and revisions, and this chapter will limit discussion to relevant historical context for the evolution of disorders in the anxious-fearful cluster. The aim is to help understand how the present Section II and III conceptualizations came to be, and to provide insights for how best to proceed going forward.

Noteworthy changes for the DSM-5 included the elimination of the Axis I/II distinction, and a new section for an alternative model of personality disorders. In the main section for all mental disorder diagnoses (including personality disorders), Section II, the structure and criteria of the personality disorder diagnoses (including the three clusters) remained unchanged from DSM-IV, ostensibly for purposes of clinical continuity. To accommodate the recommendation of the Personality Disorders Workgroup for the Alternative Model of Personality Disorders (AMPD), the American Psychiatric Association (APA) Board of Trustees created a new, unique section, Section III solely for the AMPD. This broke from past traditions in revisions where diagnoses not fully embraced by consensus or supported by research were placed in the section labeled Conditions for Further Study. Thus, the AMPD became a clinically viable alternative, arguably on equal footing with the Section II personality disorder diagnoses (see Skodol, Morey, Bender, & Oldham, 2015). In the DSM-5 Section II personality disorder criteria, the three-cluster structure from the DSM-IV remains, with AVPD, DPD, and OCPD in Cluster C (APA, 2013). For the AMPD, in Section III, the cluster structure was abandoned, and the DPD diagnosis was eliminated, suggesting that only AVPD and OCPD will be included if the alternative in its present form replaces the model.

In Search of the Core: History of Anxious-Fearful and Avoidant Pathology

Going back to early, pre-DSM roots in describing avoidant personality pathology, Hoch (1910) pointed to a reclusive character pattern, a person who was marked by tendencies to be shy, reticent, and reclusive, and to live in a world of fantasy. Around the same time, Bleuler (1911/1950, p. 391) used the label “schizoid” to describe a socially avoidant personality, a person who is “shut-in” and “comfortably dull and at the same time sensitive.” Kretschmer (1925) later divided schizoid concept into two subtypes, anaesthetic or hyperaesthetic. The anaesthetic subtype described individuals who seemed affectively insensitive, dull, and lacking in spontaneity, akin to the DSM-III schizoid personality disorder (SPD), whereas the hyperaesthetic subtype individuals seemed affectively excitable, anxious, shy, and sensitive, akin to DSM-III AVPD. For a psychoanalytical conception of what she termed a detached personality type, Horney used the descriptions “socially avoidant” (1945) and “interpersonally avoidant” (1950).

In the first DSM (APA, 1952), personality disorders were divided into three groupings that were different from the current clusters. They were Personality Pattern Disturbance, Personality Trait Disturbance, and Sociopathic Personality Disturbances (APA, 1952).¹ The modern anxious-fearful cluster has roots in the first and second groupings, with the disorder Schizoid Personality in the DSM-I Personality Pattern Disturbance grouping. In the DSM-I Personality Trait Disturbance grouping were Passive-Aggressive Personality, which included a “passive-dependent type” with features of indecisiveness and clingy dependency, and Compulsive Personality, characterized by “chronic, excessive, or obsessive concern with adherence to standards of conscience or of conformity” (APA, 1952, p. 37). (The Sociopathic grouping included antisocial and dyssocial reactions, sexual deviations, and alcohol and drug addictions.)

In the next edition of the DSM (DSM-II; APA, 1968), the higher-order groupings were eliminated, and the personality disorders were lumped together in a single group (with sexual deviations and addictions segregated to their own respective groupings outside of the personality disorders). The descriptions for the four Cluster C predecessors largely remained the same, except for Passive-Aggressive Personality, where the passive-dependent subtype was dropped. The other notable change was that Obsessive was added to the title of Compulsive Personality. These early versions of the modern anxious-fearful concept groupings notably differed in their various psychoanalytical theoretical formulations.

It was Millon (1969) who broke from psychoanalytic theory, instead drawing from personality psychology and social learning theory, and his rationale to split SPD and AVPD was eventually adopted in the DSM-III (APA, 1980). His proposal to distinguish avoidant from schizoid was not without controversy, however. Response from the psychiatric community was that the distinction was unwarranted and based on an incomplete understanding of Kretschmer’s (1925) psychoanalytically informed personality subtypes. Specifically, the criticism was that the anaesthetic and hyperaesthetic concepts were at either end of a single dimensional continuum, and thus it was inappropriate to break this continuous distribution (Livesley & West, 1986; Livesley, West & Tanney, 1985). This criticism was responded to by the psychologists working with the chair of the DSM-IV (Allen Frances) with research that showed the AVPD criteria set hung more closely with other anxious-fearful disorders (e.g., DPD), and was distinct from schizoid (Trull, Widiger, & Frances, 1987). Among the ironies in this dust-up was that Millon’s model (1973) was dimensional, but was used to frame the DSM-III (APA, 1980) personality disorders in categorical terms.

As discussion about changes for the diagnostic manual brewed during the late 1960s and early 1970s, and relevant research findings accumulated in the lead up to the transformative DSM-III in 1980, there were developments taking place in personality psychology that would greatly influence the conceptualization of the personality disorders. Also notable was Millon’s empirical work with the development of his personality measure, the Millon Clinical Multiaxial Inventory (MCMI; Millon, 1977). The MCMI influenced the structure for the then forthcoming DSM-III, separating clinical disorders from personality disorders, and including the personality disorders avoidant, dependent, obsessive-compulsive, and passive-aggressive (among others) that were to appear the DSM-III. However, the MCMI had only two higher-order groupings for personality disorders: severe personality pathology (borderline, schizotypal, and paranoid), and clinical personality patterns (the remaining personality disorders, AVPD, DPD, OCPD, and PAPD among them).

In the DSM-III (APA, 1980), personality disorders were classified on a separate Axis II to draw attention to their importance, and the modern three-cluster groupings were first described, although the clusters were not formally separated by headings until the DSM-III-R (APA, 1987). In DSM-III (APA, 1980) and DSM-III-R (APA, 1987), the Anxious-Fearful cluster included AVPD, OCPD, DPD, and PAPD. In the DSM-IV (APA, 1994) (and the DSM-IV-TR (APA, 2000) (text revision)), PAPD was dropped from Axis II Cluster C and moved to a research section, “Criteria Sets and Axes Provided for Further Study” (APA, 1994).

A significant higher-level change in the DSM-5 was the elimination of the Axis I/II distinction that separated personality disorders from clinical disorders. An unanticipated result of the original motivation to place personality disorders on a separate axis was that clinicians tended to focus their primary diagnosis on Axis I, and gave short shrift to personality disorders, according them second class status (Sanislow & McGlashan, 1998). Strong lobbying from special interest groups argued that not giving personality disorders equal footing with the major mental disorders by not placing them on the same axis gave insurance companies license to deny reimbursement for treatment on the rationale they were character problems and not “real” illnesses. The elimination of the separate axis for personality disorders may have also reflected the development of empirically supported treatments for them. Another factor was better understanding of the neurobiology. Also, prospective studies showed that remissions from personality disorders were more common than had been assumed, and thus potentially more treatable (Sanislow et al., 2009; Zanarini, Frankenburg, Hennen, Reich, & Silk, 2006).

In the DSM-5 Section II (the main diagnostic section for all clinical and personality disorders), personality disorders are categorically defined. For the anxious-fearful cluster, AVPD, DPD, and OCPD were retained (as noted, PAPD disappeared from the conditions warranting further study, with no mention of why in the section where changes to the manual are described). In the new Section III, AMPDs are dimensionally represented, several personality disorders are not included, and the higher-order cluster grouping is dropped as well (instead, the disorders are listed alphabetically). Among the anxious-fearful disorders, only AVPD and OCPD are retained.

One reason for these shifts may be the high rates of co-occurring personality disorders (Blashfield, McElroy, Pfohl, & Blum, 1994; Oldham et al., 1995; Stuart et al., 1998), especially among those who are more severely disturbed (McGlashan et al., 2000). Additionally, the cluster structure has not been supported by studies examining co-variance structures of the symptoms (Bell & Jackson, 1992; Fossati et al., 2000; Lenzenweger, Lane, Loranger, & Kessler, 2007; Sanislow et al., 2002). Another attempt to address these problems is reflected in the eleventh edition of the International Classification of Disease (ICD-11), where the Working Group has recommended that personality disorders be described in general terms with only a few subtype specifiers and more of an emphasis on severity. Their rationale included in part the high rates of observed comorbidity as well as the goal of clinical utility (Bach & First, 2018; Reed, 2018).

DSM-5 Section II Cluster C Categories

As is characteristic of the requisite general definition required for the diagnosis of any DSM-5 personality disorder, features for each of the Cluster C disorders focus on the self, and on relationships with others (see “General Definition of Personality Disorders,” APA, 2013, pp. 646–647). They include enduring patterns (at least two) of disruptions in cognition, affect, interpersonal functioning, and/or impulse control. By definition, personality disorders are stable, present across personal circumstances and social situations, and of long duration beginning around late adolescence. Echoing the “Harmful” part of Wakefield’s (1992) Harmful Dysfunction model (the harm), “personality disorders lead to clinical significant distress or impairment in social, occupational, or other areas of functioning” (APA, 2013, p. 646). The dysfunctional internal mechanism part of Wakefield’s model is notably absent from the DSM-5 definition. The three DSM-5 Cluster C disorders (AVPD, DPD, OCPD), along with the now defunct PAPD diagnosis, are briefly described in the following.

Avoidant Personality Disorder (AVPD)

The DSM-5 Section II criteria for AVPD are shown in Table 13.1. The DSM-5 Section II diagnostic criteria for AVPD include “pervasive fear of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation,” view of the self as “socially inept, personally unappealing, or inferior to others,” and “preoccupation with being criticized or rejected in social situations” (APA, 2013, pp. 672–673). The “avoidance” in AVPD is considered distinct from social avoidance seen in other DSM-5 personality disorders (such as schizotypal and schizoid) by a sense of isolating or avoiding others because those with AVPD show a “longing to be active participants in social life” (APA, 2013, p. 673), and AVPD socially avoidant behaviors are due to fears of rejection and inadequacy (see also Sanislow, Bartolini, & Zoloth, 2012; Sanislow, da Cruz, Gianoli, & Reagan, 2012).

Table 13.1DSM-5 Section II Avoidant Personality Disorder Diagnostic Criteria (APA, 2013, pp. 672–673)

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.

Dependent Personality Disorder (DPD)

The DSM-5 Section II describes the core of DPD (see Table 13.2) as characterized by the “excessive need to be taken care of” which can cause “submissive and clinging behavior” (APA, 2013, p. 675). Those afflicted with DPD are observed to lack self-confidence and report feeling “uncomfortable or helpless when alone because of fears of being unable to care for him or herself” (APA, 2013, pp. 675–676). As a result, these individuals have difficulty making decisions, taking accountability for their own actions, and expressing opinions that may differ from those of their peers (APA, 2013, p. 675). In contrast to AVPD, those with DPD may go to “excessive lengths to obtain nurturance and support from others” at the expense of their own happiness and report feeling extreme discomfort being alone (APA, 2013, p. 675). Those with AVPD instead show reclusive behavior due to fears of rejection, despite a desire for interpersonal relationships.

Table 13.2DSM-5 Section II Dependent Personality Disorder Diagnostic Criteria (APA, 2013, p. 675)

A pervasive and excessive need to be taken care of that leads to a 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.

Obsessive Compulsive Personality Disorder (OCPD)

OCPD is the last of the three anxious-fearful personality disorders in DSM-5 Section II (see Table 13.3). It is described as a “pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control at the expense of flexibility, openness, and efficiency” (APA, 2013, p. 678). This need for control leads individuals to focus their efforts on planning, which can distract them from successful and efficient completion of the task at hand. In contrast to overreliance on others (DPD) and the active avoidance of others (AVPD), an emphasis on work and productivity comes at the expense of interpersonal relationships. Those with OCPD tend to have greater interest in work than in leisure activities or developing relationships.

Table 13.3DSM-5 Section II Obsessive Compulsive Personality Disorder Diagnostic Criteria (APA, 2013, pp. 678–679)

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)	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.

Passive Aggressive Personality Disorder (PAPD) (Negativistic Personality Disorder)

As noted earlier, PAPD is not in the DSM-5. However, it is covered here even though it was phased out, first to a condition warranting further study in DSM-IV and then dropped altogether with the publication of DSM-5. The eradication of PAPD was not without objections (e.g., Blashfield & Intoccia, 2000; Wetzler & Morey, 1999), and psychometric research has supported its validity (e.g., Hopwood et al., 2009; see also Morey, Hopwood, & Klein, 2007). Moreover, significant rates of diagnostic co-occurrence of DSM-III-R PAPD with the other Cluster C personality disorders were noted, especially with AVPD (33.3 percent) and DPD (30.6 percent), less so with OCPD (16.7 percent); of interest, PAPD frequently co-occurs with other personality disorders outside of Cluster C, including BPD (66.1 percent), Narcissistic (50.0 percent), Histrionic (33.3 percent), Antisocial (25.0 percent), and Paranoid (30.6 percent) (Morey, 1988), suggesting the cross-cutting nature of the essence of PAPD of personality pathology.

Given the transient status of PAPD as a personality disorder, it should come as no surprise that not only has the diagnosis undergone significant revisions, but the concept has changed as well. Passive-aggressive was first used clinically to describe soldiers who acted out their desire not to comply with orders by passive non-compliance in the War Department Technical Bulletin, 203,² where it was classified under the rubric of “Immaturity Reactions” (War Department, 1946). The term passive-aggressive is also burdened by its folk meaning and a tendency for the term to be invoked colloquially, but the pathology is much more pernicious than commonly understood. Since its early conceptualization, PAPD was mainly couched in the psychoanalytic framework for both DSM-I and II. Those early formulations described unconscious psychodynamics involving an inability to modulate oral aggression arising from ambivalence toward the caregiver – metaphorically biting the hand that feeds you (e.g., Abraham, 1924; Fenichel, 1945). Kernberg (1976) theorized that a less than fully integrated superego was only able to primitively modulate the ego. In more contemporary cognitive theory, PAPD was thought to be rooted in beliefs related to power and autonomy, leaving PAPD individuals feeling vulnerable to the demands of others (Pretzer & Beck, 1996).

From DSM-III in 1980 to the exile of PAPD from the personality disorder diagnostic section to the research section in DSM-IV in 1994 until it was eliminated in DSM-5 in 2013, there were many changes in the diagnostic criteria stemming in large part from conceptual disagreements about the disorder. In the DSM-III (APA, 1980), PAPD retained its focus on resistance to demands for performance through some combination of two or more of the following: procrastination, dawdling, stubbornness, intentional inefficiency, or forgetfulness (APA, 1980, p. 329). For DSM-III-R (APA, 1987), features of anger were incorporated to the idea of resistance, including terms such as “sulky,” “irritable,” “argumentative,” “resents,” “scorns” (APA, 1987, pp. 357–358). Millon (1993) detailed his rationale to broaden the category of PAPD to make it more clinically significant. His rationale grew in part out of the discontent of the DSM-IV Workgroup that criticized the DSM-III-R diagnosis as being too narrow. Millon embraced the recommendation that the scope be enlarged to “… encompass non-dynamic behavioral, cognitive, and affective features that the historical clinical literature indicates often co-exist in syndromal form with passive-aggressive element” (Millon, 1993, p. 83; see Frances & Widiger, 1987). Rather than reformulate the PAPD construct, it was decided to introduce a new category to replace PAPD, and to locate it in the Appendix for further evaluation for continued use by both clinicians and researchers (Millon, 1993). The resulting diagnosis emphasized the expression of anger and irritability, including “sullen and argumentative,” “envy and resentful,” “exaggerated and persistent complaints,” and “hostile defiance” (APA, 1994, p. 735).

Benjamin (1993) disagreed with the emphasis of expression of anger that found its way into DSM-IV with Millon’s (1993) urging, and argued that the element of masochism in PAPD should not be ignored. Benjamin further argued that PAPD merited clinical attention because the very nature of this kind of personality pathology could undermine treatment. In her book, Interpersonal Diagnosis and Treatment of Personality Disorders, she provided the following descriptive prototype of passive-aggressive interpersonal process:

[A passive-aggressive] may dislike the therapist’s treatment idea, but go along with it anyway. The silliness and uselessness of the plan will soon become “apparent” through its lack of effectiveness. Similarly, suicidal acts may be escalated because of the perceived need to escape pain and suffering, but they will also be revengeful in some way. In other words, the self is attacked, but at the same time so is someone else. The anger is not direct, and it is masochistic.

(Benjamin, 1993, p. 268, emphasis added)

Given the element of inward-directed anger, Benjamin (1993) warned that if self-destructive behaviors of PAPD are not explicitly addressed in treatment, efforts that are aimed solely at addressing a comorbid condition are likely to fail. Indeed, the error of not targeting PAPD behavior could offer one explanation for the long lamented difficulties treating more severe borderline and narcissistic personality pathologies. To illustrate, she offered a case example where a patient’s self-harm behavior (cutting) was rooted in PAPD interpersonal dynamics (Benjamin, 1993). The observation is astute in light of reports that the borderline personality disorder criterion “Self-Harm” is frequently over-weighted by clinicians when making a borderline personality disorder diagnosis (Morey & Benson, 2016; Morey & Ochoa, 1989).

DSM-5 Section III Alternative Model of Personality Disorders (AMPD)

As with Section II, there is a general set of gateway criteria to qualify for any of the Section III personality disorder diagnoses. Each of the Section III personality disorders has a specific prototype rating system that explicitly directs focus on aspects of self, and on aspects of interpersonal relationships. The prototype ratings are augmented by an accompanying trait-based system for each personality disorder. In contrast to Section II personality disorders, each of the Section III alternative disorders is posed in terms of dimensions. Though the alternative disorders are similar, they also include a separate rating for functioning to more explicitly focus on impairment. “Personality functioning and personality traits also can be assessed whether or not the individual has a personality disorder – a feature that provides clinically useful information about all individuals” (APA, 2013, p. 816).

In the AMPD, only two Cluster C disorders have been retained, AVPD and OCPD. The AMPD diagnostic scheme constitutes a sort of hybrid multidimensional prototype rating of personality disorder, with two kinds of criteria, the first for personality functioning, and the second for pathological traits. The elements of personality functioning include self (identity, direction) and interpersonal (empathy, intimacy), and the elements of traits were selected from an admixture of trait models, but perhaps most clearly echo the work by Harkness and McNulty (1994; see other chapters in this volume for more detail).

In the DSM-5 Section III alternative model (see Table 13.4), AVPD functional problems in self include low self-esteem based on seeing oneself as socially inept, unappealing, or inferior, and suffering excessive feelings of shame. Unrealistic standards can lead to reluctance to pursue goals, take risks, or engage in new activities involving interpersonal contact. Interpersonally, there is a preoccupation with criticism or rejection, distortion of others’ views as negative, reluctance to get involved in social activities certain of being liked and fear of being shamed or ridiculed leads to diminished reciprocation in relationships (APA, 2013, p. 765).

Table 13.4DSM-5 Section III Avoidant Personality Disorder Diagnostic Criteria (APA, 2013, pp. 765–766)

Criteria A and B for Avoidant Personality Disorder in the DSM-5 Section III AMPD Model for Personality Disorders:
A.	Moderate or greater impairment in personality functioning, manifest by characteristic difficulties in two or more of the following four areas:
	(1)	Identity: Sense of self derived predominantly from work or productivity; constricted experience and expression of strong emotions.
	(2)	Self-direction: Difficulty competing tasks and realizing goals, associated with rigid and unreasonably high and inflexible internal standards of behavior; overly conscientious and moralistic attitudes.
	(3)	Empathy: Difficult understanding and appreciating the ideas, feelings, or behaviors of others.
	(4)	Intimacy: Relationships seen as secondary to work and productivity; rigidity and stubbornness negatively affect relationships with others.
B.	Three or more of the following four pathological personality traits, one of which must be (3) Anxiousness:
	(1)	Anxiousness (an aspect of Negativity Affectivity): Intense feelings of nervousness, tenseness, or panic, often in reaction to social situations; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of embarrassment.
	(2)	Withdrawal (an aspect of Detachment): Reticence in social situations; avoidance of social contacts and activity; lack of initiation of social contact.
	(3)	Anhedonia (an aspect of Detachment): Lack of enjoyment from, engagement in, or energy for life’s experiences; deficits in the capacity to feel pleasure or take interest in things.
	(4)	Intimacy (an aspect of Detachment): Avoidance of close or romantic relationships, interpersonal attachments, and intimate sexual relationships.

For OCPD, the DSM-5 Section III alternative model (see Table 13.5) stipulates that, in regard to self, identity and self-worth are derived through productivity (APA, 2013, p. 768), and the diagnosis is characterized by a “rigid perfectionism” (APA, 2013, p. 768). Interpersonally, these individuals show “difficulty understanding and appreciating the ideas, feelings, or behaviors of others” and relationships take a back seat to work, and are further compromised by “rigidity and stubbornness” (APA, 2013, p. 768).

Table 13.5DSM-5 Section III Obsessive Compulsive Personality Disorder Diagnostic Criteria (APA, 2013, pp. 768–769)

Criteria A and B for Obsessive Compulsive Personality Disorder in the DSM-5 Section III AMPD Model for Personality Disorders:
A.	Moderate or greater impairment in personality functioning, manifest by characteristic difficulties in two or more of the following four areas:
	(1)	Identity: Low self-esteem associated with self-appraisal as socially inept, personally unappealing, or inferior; excessive feelings of shame or inadequacy.
	(2)	Self-direction: Unrealistic standards for behavior associated with reluctance to pursue goals, take personal risks, or engage in new activities involving interpersonal contact.
	(3)	Empathy: Preoccupation with, and sensitivity to, criticism or rejection, associated with distorted inference of others’ perspectives as negative.
	(4)	Intimacy: Reluctance to get involved with people unless being certain of being liked; diminished mutuality within intimate relationships because of fear of being shamed or ridiculed.
B.	Three or more of the following four pathological personality traits, one of which must be (1) Rigid Perfectionism:
	(1)	Rigid Perfectionism (an aspect of extreme Conscientiousness [the opposite pole of Disinhibition*]): Rigid insistence on everything being flawless, perfect, and without errors or faults, including one’s own and others’ performance; sacrificing of timeliness to ensure correctness in every detail; believing that there is only one right way to do things; difficulty changing ideas and/or viewpoint; preoccupation with details, organization, and order.
	(2)	Perseveration (an aspect of Negative Affectivity): Persistence at tasks long after the behavior has ceased to be functional or effective; continuance of the same behavior despite repeated failures.
	(3)	Intimacy avoidance (an aspect of Detachment): Avoidance of close or romantic relationships, interpersonal attachments, and intimate sexual relationships.
	(4)	Restricted affectivity (an aspect of Detachment): Little reaction to emotionally arousing situations; constricted emotional experience and expression; indifference or coldness.

Note: *Detachment was changed to “Disinhibition” in an August 2015 update by the American Psychiatric Association because “Disinhibition” was the opposite pole of conscientiousness. https://psychiatryonline.org/pb-assets/dsm/update/DSM5Update_October2017.pdf (accessed August 12, 2018).

Avoidance Behaviors: Maladaptive Coping

For both AVPD and OCPD, relationships are avoided and problematic (see Table 13.6). While AVPD patients are hesitant to engage with others due to a fear of rejection, OCPD patients struggle with empathy and value work over personal relationships, and avoid others based on their perceived incompetence. Even though DPD and PAPD are not in the AMPD Section III, OCPD characteristics of difficulty completing tasks appear similar on the surface. However, for OCPD, it is “rigidity” and an inability to compromise that gets in the way, whereas DPD individuals are prone to get stuck because they are unable to make decisions on their own. As described earlier for the case of PAPD, the act of avoidance is more masochistic, a punishment of the self, rather than driven by an expression of hostility toward the other, the latter merely on the receiving end of collateral damage.

Table 13.6Avoidance behaviors and core anxiety/fear for Anxious-Fearful Personality Disorders

Personality disorder	Avoidance behaviors	Anxiety or fear
Avoidant	Relationships and intimacy	Being revealed as inept
Dependent	Assertiveness and agency	Being a not good person
Obsessive-compulsive	Intimacy and communion	Being imperfect
Passive-aggressive	Obligations and responsibilities	Being taken advantage of

Note: Avoidant behaviors may instrumentally be invoked in the service of reducing anxiety or fear, but are more likely to instead have the adverse effect of reinforcing (or not extinguishing) anxiety and fear.

Comorbidity with Clinical Disorders

The dissolution of Axis I/II so that the personality disorder categories were migrated to the same section as the clinical disorders (those formally on Axis I) reflected consensus of the field that there exists a continuity between personality disorders and clinical disorders, evidenced in part by frequent association of pathological features spanning this division. This raises the proposition that certain co-occurring clinical personality diagnoses may be linked in continuous fashion on a dimension of severity. For two Cluster C personality disorders, AVPD and OCPD, a number of studies provide evidence that this might be the case.

AVPD and OCPD Clinical Disorders Comorbidity

AVPD frequently co-occurs with a spectrum of anxiety and, to a lesser extent, with depressive disorders. Most prominent for anxiety disorders is Social Phobia (SP), which was introduced in the DSM-III. Also important is the more broadly defined successor, Social Anxiety Disorder (SAD), which was introduced in the DSM-IV to replace SP.³ This is largely unsurprising because criteria of this disorder pair are similar to AVPD in many ways. The occurrence of either panic disorder or social phobia was reported to be to up to eight to nine times more likely for those diagnosed with AVPD (Skodol et al., 1995). In a clinical sample of outpatients presenting for treatment for depression, one-third of the sample met DSM-III-R criteria for either AVPD or social phobia, or both disorders (Alpert et al., 1997).

Zimmerman and colleagues (Zimmerman, Rothschild, & Chelminski, 2005) reported that AVPD occurred in 20.3 percent of the cases of major depressive disorder, 26.1 percent of the cases of generalized anxiety disorder, and 21.8 percent of the cases of panic disorder in an outpatient sample. In the Collaborative Longitudinal Personality Study (CLPS; McGlashan et al., 2000) reported comorbidities for treatment-seeking patients who were cell-assigned to the AVPD group.⁴ For DSM-IV anxiety disorders, social phobia (38.2 percent), posttraumatic stress disorder (28.0 percent), panic disorder (22.9 percent), and generalized anxiety disorder (21.7 percent) frequently co-occurred with AVPD.

Among CLPS AVPD patients, 44.6 percent met criteria for alcohol abuse or dependence, and 32.5 percent for abuse or dependence of another substance (cases for these percentages are not mutually exclusive). Given the well-established overlap between depressive disorders and substance use disorders (e.g., Swendsen & Merikangas, 2000), depressive disorders are another connecting node, linking AVPD and other clinical disorders. Among Axis I disorders most frequently occurring with AVPD in the CLPS sample was major depressive disorder (81.5 percent) and dysthymic disorder (21.7 percent) (McGlashan et al., 2000). In a sample of older adults undergoing treatment for major depressive disorder, 11.8 percent of the patients were comorbid DSM-IV AVPD (Devanand, 2002).

Some more recent studies examining AVPD and social phobia have focused on relational problems and have added abandonment fears to the anxiety associated with close relationships (Eikenæs, Pedersen & Wilberg, 2016). In studies framed by comparisons of categorical diagnostic groupings, there is less support for a continuum model (e.g., Boone et al., 1999; Lampe & Sunderland, 2015). However, while there continues to be an interest in preserving the notion of categorical definitions for social-related anxiety, evidence for dimensional qualities is too strong to ignore (e.g., Chambless, Fydrich, & Rodebaugh, 2008; Crome, Baillie, Slade & Ruscio, 2010; Ralevski et al. 2005; Skocic, Jackson, & Hulbert, 2015; van Velzen, Emmelkamp, & Scholing, 2000).

For OCPD, Obsessive Compulsive Disorder (OCD) would seem a logical connection. Unlike AVPD and SP, however, the criteria for the disorders are less similar, the core of OCPD centered around combination of perfectionism and experiential avoidance, whereas OCD entails repetitive, ritualistic thoughts and behaviors. Nonetheless, a number of researchers have examined the continuities between the two disorders, and there is some evidence that they are on a continuum of severity. Some research has identified latent dimensions (e.g., severity) that cut across OCPD and sometimes co-occurring disorders such as depressive, anxiety, and tic disorders, but also posited the presence of subtype groupings that they argue are distinct (Nestadt et al., 2003). Others have similarly argued that those diagnosed with both OCPD and OCD represent a specific, more severe subtype of OCD (e.g. Coles, Pinto, Mancebo, Rasmussen, & Eisen, 2008; Garyfallos et al., 2010). The preponderance of research, however, suggests the presence of core dimension of severity between OCPD and OCD (e.g., Gordon, Salkovskis, Oldfield & Carter, 2013; Lochner et al., 2011). OCPD does have associations with other clinical disorders, in particularly eating disorders (e.g., Serpell, Livingstone, Neiderman, & Lask, 2002; Thornton & Russell, 1997). Not surprisingly, features of these disorders share the common element of striving for perfection.

In sum, AVPD frequently co-occurs with a spectrum of anxiety and depressive disorders. The frequency of co-occurrence with depressive disorders varies widely and is likely somewhat dependent on the sample. Among anxiety disorders, social phobia is noteworthy because features of that disorder are similar in many respects to AVPD criteria, but also because of the dimension that runs from normal shyness to a disabling social reclusiveness. For OCPD, the relation with OCD as well as various forms of eating disorders is notable, particularly the features of perfectionism and experiential avoidance. With CLPS data, analysis of a subset of OCPD symptoms revealed a unique link to OCD (Eisen et al., 2006). Other research has identified a dimension of “self-control” anchored on either end by impulsivity (OCD) and over control (OCPD) as a salient cross-cutting feature bridging the two categorical diagnoses (Pinto, Steinglass, Greene, Weber, & Simpson, 2014). Treatment outcome research using exposure with response prevention for OCD found poorer outcomes were associated with the OCPD-related feature perfectionism. Evidence for dimensional conceptualizations may be most compelling when intermediate phenotypes or components of the diagnoses are the focus of study. Overall, these sorts of findings raise questions about the specificity and coverage of the categorical diagnostic definitions.

Findings such as these thematically suggest that well-studied cross-cutting dimensions offer another way to break free from categorical comparisons and identify higher-order constructs that might better correspond to basic trait models. Examples might include: self-esteem (e.g., Gyurak, & Ayduk, 2007; Lynum, Wilberg & Karterud, 2008), rejection sensitivity (e.g., Ayduk, Gyurak, & Luerssen, 2008; Downey & Feldman,1996; Kross, Egner, Ochsner, Hirsh, & Downey, 2007), perfectionism, dependency (Blatt, D’Afflitti, & Quinlan, 1976; Hewitt & Flett, 1991), and experience avoidance (e.g., Wheaton & Pinto, 2017). Clearly, many of these dimensions cut across not only clinical disorder–personality disorder boundaries, but also run through various personality disorders, including other, non-Cluster C disorders.

Pathoplasticity

Personality disorders and clinical disorders may also be related via the concept of pathoplasticity. Pathoplasticity is theoretically agnostic about the presence of a shared etiology and instead emphasizes “the influence of one condition on the presentation or course of the other” (Shea et al., 2004, p. 500). In other words, the presence of one disorder impacts the course and treatment outcome of the other, but they do not necessarily stem from the same pathology. With CLPS data, Shea and colleagues (2004) found a significant association for the longitudinal associations of AVPD and Axis I anxiety disorders. This finding suggested a continual interplay of AVPD with social phobia and obsessive-compulsive disorder over the course of time (Shea et al., 2004). In contrast, major depressive disorder was more related to borderline personality disorder than AVPD when controlling for depressed mood.

Using the same CLPS data, Warner and colleagues (2004) tested the relations of personality traits to DSM-IV-TR symptoms using a cross-lagged structural modeling approach. The changes in avoidant personality traits defined with the Five-Factor Model using an approach devised by Lynam and Widiger (2001) preceded changes in the AVPD criteria. The Warner results provided a conceptual link between personality traits and personality disorders implied by the DSM, and support for the addition of personality traits in the DSM-5.

These comorbidities and dimensional associations raise a question related to the AMPD approach to bifurcate personality traits and the more traditional personality disorder self–other definitional features. Why would personality traits not have similar implications for clinical disorder diagnoses more broadly? If, for instance, AVPD and SP/SAD, or OCPD and OCD are indeed continua of severity, why would trait-level specifications be limited only to the personality disorder portion of the continuum? Another alternative would be to define the symptomatic pathology in personality disorders in much the same way as the clinical disorders, and to construct trait models based on personality psychology to identify constellations that would pose risk or resilience in the course of mental disorders more generally. In any event, these potentially contiguous dimensions that cut across the traditionally separate clinical and personality disorders raise the issue of where to carve nature between “disorders” and “traits” (cf. Gangestad & Snyder, 1985).

Biological Mechanisms

One criticism of the DSM-5 Personality Disorders Workgroup was the lack of consideration of biologically-based and temperamental models of personality disorder diagnoses, or at least published consideration of the pros and cons of such models (see special issue of Journal of Personality Disorders). Notably absent was Cloninger’s Seven Factor Model of Temperament and Character (Cloninger, Svrakic, & Przybeck, 1993) as well as the Psychobiological Model offered by Siever and Davis (1991). This is especially salient because there has been a burgeoning interest in the biological and neuroscientific study of personality disorders, although much has been directed at borderline personality disorder (Campbell et al., 2007; Donegan et al., 2003; Etkin, Prater, Hoeft, Menon, & Schatzberg, 2010; Schmidt & Jetha, 2009). Some of these biological studies addressed personality disorders in the anxious-fearful cluster (e.g., AVPD; Denny et al., 2015), but most often, reports of these disorders are from studies where one has been employed as a contrast condition (e.g., AVPD serving as contrast group to borderline, relative to normal controls; Herpertz et al., 2000).

The Siever and Davis model (1991) was prescient in that it posited intermediate phenotypes that had been well studied outside of the context of the DSM framework, thereby not constraining the dimensional qualities of the construct on the basis of study inclusion rules that might limit meaningful variance. Their constructs were cognitive/perceptual organization, impulsivity/aggression, affective instability, and anxiety/inhibition, and they emphasized that these biological dimensions cut across Axis I/II, that is, both clinical and personality disorders (Siever & Davis, 1991). However, there was not good one-to-one correspondence to the various personality disorders (see Shea et al., 2004), and this may be one reason why they were not included. On the other hand, those dimensions themselves were supported by a preponderance of biological and genetic evidence, and it may be that it was the DSM that was the limiting factor when attempting to clarify the relation to the dimensions and personality disorder categories (see Cuthbert, 2005; Eaton, Krueger, South, Simms, & Clark, 2011).

Nonetheless, given advances in integrative neuroscience, the potential to further tease apart the mechanisms of personality pathology could offer rewards for better treatment targets. Some personality researchers have attempted to link five-factor traits to structural features of the brain (e.g., DeYoung et al., 2010; Grazioplene, Chavez, Rustichini, & DeYoung, 2016).

Example: Using the NIMH RDoC to Research Anxious-Fearful-Avoidant Pathology

Clearly, there are many commonalities in the neural structures and pathways involved in behaviors among Cluster C personality disorders, and the NIMH RDoC offers a framework to organize the relations of these systems and behaviors (Sanislow et al., 2010). For example, an obvious domain is Negative Valence, which includes constructs for anxiety and fear. Yet other midbrain pathways are involved in processing fear/threat stimuli as well as social bonding, and connections to regions of cortex such as OFC and vmPFC. But there are complicated behaviors that need to be accounted for to understand the clinical problems with anxious-fearful-avoidant pathology. In the RDoC, the domain “positive valence systems” is defined as “responsible for responses to positive motivational situations or contexts, such as reward seeking, consummatory behavior, and reward/habit learning” (RDoC Matrix Website). The construct “approach motivation,” which lies in this domain, may provide a useful framework for thinking about AVPD and the mechanisms that underlie it. The RDoC approach describes motivation as the “mechanisms/processes that regulate the direction and maintenance of approach behavior influenced by pre-existing tendencies, learning, memory, stimulus characteristics, and deprivation states,” towards “innate or acquired cues, implicit or explicit goals” (RDoC Matrix Website). Taken together with the description of approach motivation put forth in RDoC, establishing meaningful social relationships can be seen as a goal for AVPD patients, but the need to address systems involved in the anticipation of anxiety provoked by potential social interactions is important. On the other hand, regulating that anxiety by avoiding social interaction can inhibit these patients from seeking these goals, promoting further social withdrawal.

The sub-constructs of approach motivation outlined in the RDoC further describe behavioral patterns associated with AVPD. For example, “reward valuation” refers to the ability to estimate the likelihood of an outcome as well as its value, and focuses on the notion of “calibration” through personal biases and experiences (RDoC Matrix Website). In this way, individuals with AVPD can be seen as predisposed to view the likelihood of a positive social interaction as low, leading them to become withdrawn. Similarly, “action selection” describes the way cost/benefit computations occur in a decision-making context (RDoC Matrix Website). In this view, those suffering AVPD might be seen as prone to repeatedly making maladaptive choices based on their errant analyses.

Beyond approach motivation, connecting the symptoms of AVPD with RDoC may help clarify neural and psychological mechanisms of AVPD, as well as those in other Cluster C personality disorders. Much of the neural circuitry that supports relevant aspects of approach motivation is also relevant to other important constructs in RDoC that pertain to AVPD. For example, the amygdala is related to expectancy, reward prediction error, action selection within approach motivation, and is also tied to affiliation and attachment within social processes. In addition, the RDoC notes other midbrain areas, such as striatum, substantia nigra/ventral tegmental area (VTA), and nucleus accumbens (NAcc), which are involved in approach motivation and certain fear and anxiety responses. The RDoC also implicates higher cortical structures, such as orbitofrontal cortex (OFC) and the pathways linking the limbic system and cortex in relevant processes. This suggests that disrupted activity in certain midbrain or cortical structures, or the connections between them, may play a role in AVPD, along with physiological changes associated with the stress response, for example, changes in heart rate and skin conductance. For the person suffering AVPD, the cognitive control of emotion may be accomplished through avoidance behaviors.

There are also parallels between DSM-5 symptoms and RDoC constructs for other Cluster C personality disorders. In the case of DPD, the RDoC indicates similar physiology may be affected as in AVPD, despite different symptoms. As noted, the DSM-5 describes DPD as an “excessive need to be taken care of” which can cause “submissive and clinging behavior” (APA, 2013, p. 675). Dependent patients lack self-confidence and feel “uncomfortable or helpless when alone because of fears of being unable to care for him or herself” (APA, 2013, pp. 675–676). As a result, these individuals are indecisive, avoid responsibility for their actions, and they are reluctant to express opinions that may differ from those of their peers (APA, 2013, p. 675).

Unlike those with AVPD, DPD individuals may go to “excessive lengths to obtain nurturance and support from others” at the expense of their own happiness and feel extreme discomfort being alone (APA, 2013, p. 675). AVPD patients instead show reclusive behavior due to fears of rejection, despite a desire for interpersonal relationships. These differences may reflect shared underlying mechanisms for the two diagnoses. The RDoC shows similar parallels for the DPD symptoms – within the negative valence systems domain, acute threat and potential threat reflect the “activation of the brain’s defensive motivational system” in situations of “perceived danger,” whether that threat is something specific or more “ambiguous” (RDoC Matrix Website). Action selection, within the positive valence systems, also proves useful in describing DPD symptoms, particularly with respect to seeking out relationships and support from others through “excessive” means (RDoC Matrix Website; APA, 2013, p. 675). Further, social processes involving affiliation and attachment outlined in RDoC suggest the way disruptions in this area may lead to “over-attachment,” which closely relates to “submissive and clinging behavior” and excessive reliance on others that characterizes DPD (APA, 2013, p. 675).

RDoC is useful for analyzing DPD symptoms from the DSM-5 grouping, and potentially connecting them to the physiological mechanisms that appear in DPD as well as similar symptoms in other DSM-5 constructs. Similar to AVPD, midbrain structures involved in fear/stress responses and social attachments, as well as reward pathways seem to be affected, such as hypothalamus, amygdala, bed nucleus of the stria terminalis (BNST), and NAcc, as well as higher cortical structures involved in processing these responses, including vmPFC and OFC (RDoC). Similar pathways are also implicated to other aspects of the disorder as well – amygdala is implicated in action selection and in processes of social attachment and bond formation. Neurotransmitters involved in these systems also show similarities across RDoC, particularly those associated with affiliation and attachment like oxytocin and vasopressin, and in fear and reward pathways, like dopamine. In addition, the autonomic nervous system is closely linked to fear and stress responses, which mirrors the anxiety characteristic of AVPD patients, albeit with a different basis. Other RDoC constructs, such as agency within the social processes domain, also seem to be affected, but the neural structures implicated in these processes have not yet been fully established.

Similar to AVPD and DPD, OCPD symptoms align closely with constructs in the RDoC pertaining to threat and reward processing, as well as social affiliations and attachments. OCPD patients show anger or frustration when tasks are not completed in the way they feel is best. This lack of control (and deviance from “flawless” ideals) can be threatening, and acute stress responses may be activated. More generally, reward systems may be activated that support the pursuit of perfectionism, and explain rigid behavior in these patients. Disruptions in social attachments and affiliations seem to be at work in this disorder as well, particularly in the way that perfectionism and productivity take precedence over relationships.

A critical distinguishing feature of social behaviors in OCPD (compared to AVPD or DPD) is a decreased ability to understand the emotions of others and to express intimate feelings. Many of these behaviors are described under the construct perception of others, within social processes. The physiological underpinnings of these processes are not fully established, but hormones associated with attachment like oxytocin and vasopressin as well as certain cortical structures, such as medial prefrontal cortex (mPFC), may be implicated. In addition, habit formation described in RDoC recalls symptoms of OCPD, such as hoarding and focus on “details, rules, lists, order, organization, or schedules” (APA, 2013, p. 678). Such behaviors may be mediated by similar midbrain structures (substantia nigra (SN), VTA, and striatum), as well as cortical areas (mPFC) involved in planning.

Concluding Thoughts

The historical vantage point of this chapter highlights a sundry of lumping, splitting, re-grouping, and reorganizing of the salient types of clinical problems related to chronic kinds of anxiety, fear, and avoidance in attempts at formal classification dating back to the turn of the last century. As discussed, there have been different ideas about how these problems come about, and varying ideas about the underlying dynamics, whether views of those mechanisms are shaped by a psychoanalytic, psychological, behavioral, or biological approaches. But, strikingly, conceptions of this kind of personality pathology have largely remained the same even though various groupings and divisions have come and gone, in some instances, more than once.

Clearly there are many forces at work, including guild interests of psychiatry and psychology, and divisions and cross-alliances within and between camps (see Volume 26, Number 6 of the Journal of Personality Disorders for illustrations). There are scientific issues, too. Other chapters in this volume discuss the merits of competing models, factors that are no doubt relevant for efforts going forward. It is also important to keep in mind the different goals of clinical utility and research validity in formulating clinical tools for diagnosis and carrying out research on the structure or mechanisms of personality pathology (Skodol, 2012). The goal of clinical diagnosis is practical, and not primarily an academic enterprise. The “caseness” of a categorical diagnosis helps clinicians to recognize a prototype of a set of problems and to begin to think about a treatment plan, to communicate to third party payers, including documenting disability. The goal of clinical research is to achieve valid conceptions of psychopathology. Clarifying the mechanisms – psychological and biological – and how they are manifest in the interpersonal processes that are the space of personality is the challenge (see Carson, 1989). Transdiagnostic constructs and alternative research strategies such as RDoC offer possibilities to see things in a different light. Our review of the anxious-fearful-avoidant pathologies shows us that research constrained to some variant of the DSM structure may get us no farther than a reshuffled deck of cards.

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The authors are grateful to Marcia K. Johnson for her helpful suggestions for this chapter and insightful discussions about the subject herein.

¹This excludes a fourth grouping for transient, situational disorders, later represented outside of personality disorders as Adjustment Disorders from DSM-III onward.

²The War Department Technical Bulletin 203, released October 10, 1945, and reproduced in the Journal of Clinical Psychology (War Department, 1946) provided a nomenclature of psychiatric disorders and reactions, and was the precursor to the first edition of the DSM. In addition to the diagnosis passive-aggressive, there also was a related disorder, passive-dependent that foreshadowed DPD. Working in the Office of the Surgeon General, William C. Menninger (who later became a Brigadier General) chaired the committee that produced the document.

³In the DSM-IV, Social Phobia was subtitled Social Anxiety Disorder; for DSM-5, Social Anxiety Disorder had the subtitle Social Phobia.

⁴Cell assignment to one of the four CLPS index personality disorders required diagnosis from a structured interview, and an additional confirmation using either the DSM-IV scoring algorithm of the Schedule of Non-Adaptive and Adaptive Personality, or a blind Prototype Rating completed by the referring clinician; thus, occurrence of the four primary personality disorders in CLPS exceeded the number for the cell-assigned disorders (Skodol et al., 2005).