Personality disorders: general diagnostic principles; anankastic (obsessive-compulsive), anxious (avoidant), and dependent personality disorders. Other specific personality disorders, including narcissistic personality disorder
The anxious and fearful personality disorders, anankastic (obsessive-compulsive), anxious (avoidant) and dependent, and the other specific types of ICD-10, above all narcissistic personality disorder. How each is recognised, told apart from the anxiety disorders and OCD it resembles, and treated with psychotherapy, with drugs kept for comorbid illness.
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- Checked 26 Oct 2026
Contents6 sections
At a glance
- Cluster C personality disorders are anxious and fearful: anankastic (obsessive-compulsive), anxious (avoidant) and dependent. They meet the same general criteria as every personality disorder: lasting, pervasive and inflexible, beginning by early adulthood, with distress or impairment.
- Anankastic personality is perfectionism, rigidity and a need for control that feel right to the person (ego-syntonic). OCD is defined by obsessions and compulsions that the person recognises as excessive and resists (ego-dystonic).
- Avoidant personality is a pervasive fear of criticism and rejection in someone who wants relationships; it overlaps heavily with social anxiety disorder. A schizoid person, by contrast, does not want them.
- Dependent personality is an excessive need to be cared for, with submissiveness, fear of being alone and difficulty making decisions; it can keep a person in an abusive relationship.
- Narcissistic personality is grandiosity, a need for admiration and a lack of empathy. ICD-10 places it under other specific personality disorders (F60.8), with passive-aggressive and others; DSM-5 puts it in cluster B.
- Treatment is psychological: schema therapy, CBT and short-term dynamic psychotherapy. No drug treats a personality disorder; antidepressants are for comorbid depression, anxiety disorders or OCD.
- Cluster C traits change little with age, and they make comorbid depression and anxiety harder to treat.
Definition and overview
A personality disorder is a lasting pattern of inner experience and behaviour that departs markedly from what the person's culture expects, is pervasive and inflexible across situations, begins in adolescence or early adulthood, causes distress or impairment, and is not explained by another mental disorder, a substance or brain disease. The general principles, the clusters and ICD-11's dimensional model are set out in full with the cluster A and B personality disorders.
| ICD-10 | ICD-10 name | DSM-5 name | DSM-5 cluster |
|---|---|---|---|
| F60.5 | Anankastic | Obsessive-compulsive personality disorder | C, anxious or fearful |
| F60.6 | Anxious (avoidant) | Avoidant | C |
| F60.7 | Dependent | Dependent | C |
| F60.8 | Other specific: narcissistic, passive-aggressive, eccentric, haltlose, immature, psychoneurotic | Narcissistic (passive-aggressive was dropped) | B |
| F61 | Mixed and other | Other specified or unspecified | none |
ICD-11 has no types: it diagnoses one personality disorder, graded mild, moderate or severe, and describes its traits with five domains. Cluster C pictures map mainly onto negative affectivity (anxiety, shame, low self-worth), anankastia (perfectionism and control) and detachment (avoidance of closeness); narcissism maps onto dissociality (entitlement, lack of empathy) with negative affectivity in its vulnerable form.
Point at a name or a part to light it.
ICD-11 drops the personality types. It diagnoses one personality disorder, by how severely it disturbs the person's sense of self and their relationships, from mild to severe, and then describes it with any of five trait domains. The older cluster C types map mainly onto negative affectivity, detachment and anankastia, and narcissism onto dissociality, often with negative affectivity.
Simplified: the lines are approximate: a person is described by their own traits, not their old type, and the types often draw on several domains; ICD-11 also has a borderline pattern specifier, kept for access to the treatments built for borderline personality disorder.
4 sources
- World Health Organization. Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural and Neurodevelopmental Disorders (CDDR). WHO, 2024. Personality disorders and related traits, 6D10 and 6D11.
- Tyrer P, Mulder R, Kim YR, Crawford MJ. The development of the ICD-11 classification of personality disorders: an amalgam of science, pragmatism, and politics. Annual Review of Clinical Psychology, 2019;15:481–502.
- Bach B, First MB. Application of the ICD-11 classification of personality disorders. BMC Psychiatry, 2018;18:351.
- Semple D, Smyth R. Oxford Handbook of Psychiatry, 4th edition. Oxford University Press, 2019. Chapter 12, Personality disorders.
Etiology and pathophysiology
The causes are less studied than in cluster B. Personality traits are about 30 to 50 per cent heritable, and the cluster C disorders share genes and temperament with the anxiety disorders:
- behavioural inhibition, a shy, fearful, withdrawn temperament from toddlerhood, predicts avoidant personality and social anxiety disorder;
- overprotective, controlling or critical parenting, and teasing, rejection or bullying in childhood, are reported often in avoidant and dependent personality;
- in schema therapy terms, early maladaptive schemas, lasting core beliefs formed in childhood, drive the traits: "I am defective" and "I will be rejected" in avoidant personality, "I cannot cope alone" in dependent personality, "mistakes are unforgivable" in anankastic personality;
- psychodynamic accounts see narcissism as a defence: a grandiose self built over a fragile self-esteem, after a childhood of coldness, overvaluation, or both.
Clinical features
Anankastic (obsessive-compulsive) personality disorder
A pervasive preoccupation with order, perfection and control, at the cost of flexibility, openness and efficiency.
| Feature | What it looks like |
|---|---|
| Doubt and caution | excessive checking of decisions; indecisiveness |
| Preoccupation with details | rules, lists, order and schedules, until the point of the task is lost |
| Perfectionism | tasks not finished because they are never good enough |
| Conscientiousness | devotion to work and productivity at the expense of pleasure and friendships; rigid about morals and ethics |
| Pedantry and rigidity | stubborn adherence to convention; little warmth shown |
| Control of others | insisting others do things exactly their way; reluctant to delegate |
DSM-5 adds hoarding of worthless objects and miserliness, and requires four of eight features.
| Anankastic personality disorder | Obsessive-compulsive disorder | |
|---|---|---|
| Experience | ego-syntonic: the traits feel right and are defended | ego-dystonic: obsessions are unwanted, recognised as excessive and resisted |
| Core features | perfectionism, rigidity, control, devotion to work | intrusive obsessions and neutralising compulsions or rituals |
| Course | lifelong, stable | usually chronic, waxing and waning, with onset in childhood or early adulthood |
| Treatment | psychotherapy | CBT with exposure and response prevention, SSRIs |
The two can coexist: a minority of people with OCD also have the personality disorder, and their OCD tends to respond less well.
Anxious (avoidant) personality disorder
A pervasive feeling of inadequacy and a fear of criticism and rejection that keep the person from the relationships they want.
| Feature | What it looks like |
|---|---|
| Tension and apprehension | persistent and pervasive |
| Feeling inferior | believes they are socially inept, unappealing or inferior |
| Fear of criticism | preoccupied with being criticised or rejected in social situations |
| Conditional contact | unwilling to get involved with people unless certain of being liked |
| Restricted life | avoids work and activities with significant contact with people; restricts lifestyle for security |
The main differentials:
| Condition | How it differs |
|---|---|
| Social anxiety disorder | overlaps so heavily, above all in its generalised form, that many see the two as one condition of different severity; avoidant personality is more pervasive, earlier and more tied to self-image |
| Schizoid personality | detachment without wanting relationships, and without fear |
| Dependent personality | the avoidant person avoids relationships for fear of rejection; the dependent person clings to them for fear of being alone |
| Autism | social difficulties from early childhood, with restricted interests and differences in social communication |
Dependent personality disorder
An excessive, pervasive need to be looked after, leading to submissive, clinging behaviour and fear of separation.
| Feature | What it looks like |
|---|---|
| Others decide | encourages or allows others to make the important decisions in their life |
| Subordination | puts their own needs below those of the person they depend on; complies unduly |
| No demands | unwilling to make even reasonable demands on others |
| Helpless alone | uncomfortable alone, from exaggerated fear of being unable to cope |
| Fear of abandonment | preoccupied with being left to care for themselves; when a relationship ends, urgently seeks another |
| Need for reassurance | cannot make everyday decisions without excessive advice |
People with dependent personality may stay in abusive or exploitative relationships, so the history asks directly about violence and coercion. Dependence that follows agoraphobia, depression or a chronic physical illness is not a personality disorder.
Narcissistic personality disorder
A pervasive grandiosity, in fantasy or behaviour, a need for admiration and a lack of empathy. DSM-5 requires five of nine features:
| Domain | Features |
|---|---|
| Grandiosity | an inflated sense of self-importance; fantasies of unlimited success, power, brilliance or ideal love; a belief in being special, understood only by special people |
| Need for admiration | requires excessive admiration |
| Entitlement | expects favourable treatment and automatic compliance |
| Relationships | exploits others; lacks empathy; envious, or believes others envy them |
| Attitude | arrogant, haughty behaviour |
Clinicians describe two forms. The grandiose (overt) form is confident, dominant and exploitative. The vulnerable (covert) form is shy, hypersensitive to criticism, ashamed and resentful, and comes to clinics more often, with depression. A setback, such as a lost job, a divorce or public humiliation, can bring rage, depression and a high risk of suicide, sometimes without warning. Comorbid substance misuse and depression are common.
Passive-aggressive and other specific types
Passive-aggressive (negativistic) personality is a pattern of passive resistance to demands for adequate performance: procrastination, deliberate inefficiency, forgetfulness, stubbornness and sulking, with complaints of being misunderstood and unappreciated and resentment of authority. It was in DSM-III, moved to DSM-IV's appendix and was dropped by DSM-5; ICD-10 keeps it, with the eccentric, haltlose (drifting, aimless), immature and psychoneurotic types, under F60.8. These are rarely diagnosed, and ICD-11 describes such pictures through severity and trait domains.
Diagnosis and management
Assessment
The diagnosis follows the general rules: a longitudinal history from adolescence, an informant's account, more than one interview, and care not to mistake a current depression or anxiety disorder for personality. Patients with cluster C traits usually present with depression, anxiety, panic, OCD or burnout, and the personality is found in the history. Structured interviews, such as the IPDE or SCID-5-PD, support the clinical picture.
| Presents with | Look for |
|---|---|
| Social anxiety, loneliness | avoidant personality |
| Depression after a loss of a partner or carer | dependent personality |
| Burnout, work conflict, marital strain | anankastic personality |
| Depression after a humiliation or failure, rage, entitlement in clinic | narcissistic personality |
Treatment
Treatment is psychological, usually as an outpatient, and aims at more flexible traits and better functioning, not a change of character.
| Therapy | What it does |
|---|---|
| Schema therapy | identifies and changes early maladaptive schemas with cognitive, experiential and behavioural techniques; in a multicentre Dutch trial it led to more recovery than clarification-oriented therapy or usual care for cluster C, paranoid, histrionic and narcissistic personality disorders |
| Cognitive behavioural therapy | tests beliefs ("if I make a mistake I will be rejected"), with graded exposure to avoided situations, assertiveness training and behavioural experiments |
| Short-term dynamic psychotherapy | explores the conflicts and relationship patterns behind the traits; in a randomised trial it helped cluster C patients as much as cognitive therapy |
| Group therapy | social skills and exposure in a safe setting, especially for avoidant personality |
Each disorder brings its own pitfalls. Anankastic patients turn therapy into another task to be done perfectly, and need help to tolerate imperfection and uncertainty. Avoidant patients drop out when they feel judged; a warm, steady therapist and graded goals keep them. Dependent patients can transfer their dependence to the therapist, so the therapy has an agreed length and aims at independent decisions. Narcissistic patients alternately idealise and devalue the therapist; mentalisation-based, transference-focused and schema approaches are used, and the clinician stays respectful without colluding with entitlement.
No drug is licensed for a cluster C or narcissistic personality disorder, and none changes personality. Drugs treat comorbid illness: an SSRI or SNRI for depression, an anxiety disorder or OCD; for avoidant personality with social anxiety disorder, the CBT and SSRIs used for social anxiety often reduce avoidance too. Benzodiazepines are avoided because of dependence, a particular risk in dependent personality.
Epidemiology
Estimates vary widely with the method. Taken together:
| Type | Approximate community prevalence | Notes |
|---|---|---|
| Anankastic (OCPD) | 1 to 8 per cent | often the commonest personality disorder in community surveys; more men |
| Avoidant | 1 to 2 per cent | equal in men and women; common in anxiety clinics |
| Dependent | below 1 per cent | diagnosed more often in women |
| Narcissistic | below 1 to about 6 per cent | more men; commoner in clinical and forensic samples |
Personality disorder of any type is found in about 1 in 10 primary care attenders, mostly among those presenting with depression or physical symptoms. Cluster C disorders are common in anxiety and depression services, often with each other and with cluster B traits. Avoidant personality is found in a large share of people with generalised social anxiety disorder.
Prognosis
Cluster C traits tend to be stable through life, without the decline with age that cluster B shows, and anankastic traits can become more marked in later life, when rigidity copes poorly with retirement, illness and loss. Depression is a commoner outcome of anankastic personality than OCD.
The traits worsen the course of comorbid depression and anxiety, but psychotherapy helps: in trials of schema therapy and short-term dynamic therapy, many patients no longer met the criteria at follow-up. The outlook is better with motivation, a stable relationship or job and no comorbid substance misuse. In narcissistic personality, outcome depends on the capacity to bear setbacks; a major loss brings the highest risk of depression and suicide, and some improve in middle age as achievements and relationships temper grandiosity.
Check yourselfAnswer, then say how sure you were: a lucky guess still counts as a weak point.
1A 42-year-old accountant is referred because his rigid perfectionism is costing him promotions. He redoes reports until they are flawless, cannot delegate, works most evenings and insists his family load the dishwasher his way. He sees his standards as right and has no intrusive thoughts or rituals he wishes to resist. What is the most likely diagnosis?
2A 26-year-old woman longs for friends and a partner but turns down invitations because she is sure she will be judged as boring and inferior. Since adolescence she has avoided jobs that involve meeting people. Which description fits best?
3Where does narcissistic personality disorder sit in ICD-10?
4A 35-year-old woman cannot make everyday decisions without her husband's advice, agrees with him to avoid any disagreement and says she could not cope alone. In clinic she discloses that he hits her. What is the most important first step?
5A man with avoidant personality disorder asks whether a tablet could cure his personality. What is the most accurate answer?