risperidone or quetiapine) is indicated.

Narcissistic personality disorder

Sense of self-importance, grandiosity, and entitlement; in need of admiration and lack of empathy; jealousy and improper rage with criticism. It occurs mostly in low-educated patients.

Management: Patients pose significant challenges in establishing a therapeutic relationship. The clinician may have to tolerate a lengthy period of time of vulnerability and self-protection before trust develops.

Clinical strategy for Cluster B

Cluster B patients are associated with testing and pushing the limits of the treatment relationship. They are manipulative and demanding (attention), and tends to change the rules. Clinicians should be firm (stick to the treatment plan), fair (not punitive or derogatory), and consistent in rules and boundaries in a quest to build a relationship.

III. Cluster C Personality Disorders — “Worried”

These are mainly characterized by anxiety and preoccupation with criticism or rigidity.

Avoidant personality disorder

Patients are socially inhibited, feeling inadequate or inferior, shy and lonely, hypersensitive to criticism, preoccupied with rejection, and unwilling to get involved with people. Some patients may be similar to vulnerable narcissists and/or social anxiety disorder. It is important to understand underlying self, interpersonal and emotional schemas to optimize treatment alliance.

Dependent personality disorder

Submissive and clinging, feeling inadequate and helpless; avoiding responsibility and making decisions; always in need of care.

Management: Psychotherapy is the main treatment. The clinician must be alert to the potential for the patient to withdraw emotionally and psychologically. Additional challenges may occur when the clinician attempts to encourage more independence.

Obsessive-compulsive personality disorder (OCPD)

Preoccupied with details, orderliness, perfectionism, and control; often consumed by the details of everything and lose the efficiency (goals); inflexible morals and values. It is different from obsessive compulsive disorder (OCD), an anxiety disorder. OCD is manifested by the patient’s experience of obsessive thoughts and compulsive behaviors. There is only modest co-occurrence between OCPD and OCD. Both disorders are mainly treated with cognitive-behavioral therapy (CBT). OCD may also need SSRIs.

Passive-aggressive (negativistic) personality disorder

This diagnosis was initially included in Cluster C, but shifted to disorders in need of further study in DSM-IV, and deleted altogether in DSM-5.

Clinical strategy for Cluster C

Patients are worried but controlling, and their words may be inconsistent with actions. These may ruin the treatment. Therapists should give clear recommendations, but not force the patient into decision. Be caring, sympathetic, and patient. Building a therapeutic relationship with patients with Cluster C disorders is facilitated because these patients are willing to take responsibility for their problems and more readily engage in a dialogue with the clinician to try to solve them in comparison to patients with more severe Cluster A or B disorders.