Avoidant Personality Disorder

DSM-IV Criteria

avoids occupational activities unwilling to get involved with people fear of being shamed or ridiculed preoccupied with being criticized or rejected inhibited because of feelings of inadequacy views self as socially inept, or inferior to

others is unusually reluctant to take personal risks

4/7 for diagnosis

.5 to 1% of general population

ICD-10: Anxious Personality

History Kretschmer (1952) – “hyperasesthetic shut-in

character” Fenichel (1945) – phobic personality Horney (1945) – interpersonally avoidant character Millon (1969) – avoidant personality

DSM I and II (1952, 1968) described the inadequate personality had overlap with DEP, SZD and AVD

DSM-III (1980) – 1st appearance

Avoidant Styles

No sharp boundaries exist between normality and pathology.

Sensitive style (Oldham and Morris)

Hesitating (Millon)

E ISensitive

Avoidant

Avoidant Style

Avoidant PD in other culture

Taijin kyoufu (Japan)

Interpersonal sensitivity Fear and avoidance

self others

Western view

Collectivist view

AVD in Media

Not good lead characters

Superman (Clark Kent) The Mask (Jim Carrey) Four Weddings and Funeral (Hugh Grant) Primal Fear (Aaron Stampler character) *Zelig (Woody Allen)

Millon - evolutionary

Millon - subtypes

Self-deserting (depressive) Phobic (dependent) Conflicted (negativistic) Hypersensitive (paranoid)

0

30

60

90

120

150

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0 11 SDFPAR

AVD

HIS

DEPSZD

ANT

NAR

Assured-Dominance

Unassured-Submissive

Warm-Agreeable

Cold-Hearted

Gregarious-Extraverted

Unassuming-Ingenuous

Aloof-Introverted

Arrogant-Calculating

PhobicNo representation

N E O A C

SZD L

AVD H L

DEP H

HST H

NAR H h

ANT L L

COM h

SZT H L l

BDL H l l

PAR h L

See commentary below slide to understand letters and numbers

MMPI – Two Point Codes

2/7, 7/2 (depression, psychasthenia)

0/2, 2/0 (introversion, depression)

0/7, 7/0 (introversion, psychasthenia)

Co-morbidity

Social Phobia Generalized Type

AVD

Social Phobia exposure to the feared social situation

almost invariably provokes anxiety, which may take the form of a panic attack

person recognizes that the fear is excessive or unreasonable

feared situation is avoided or endured with intense anxiety or distress

avoidance, anxious anticipation or distress in the feared social or performance situations interferes significantly with person’s normal routine

Interview Considerations

Turkat (1990)

1) complains of evaluation anxiety 2) complains of depression 3) complains of pain suffering (i.e.,

gastrointestinal pain, headache, back pain that seem tension related)

Interview Considerations

Not pose difficulties May be very open Explore trauma history Extremely sensitive (thin skinned) Confrontation not effective Anxious while interviewed

Interview Themes Self-critical, self-doubts Socially detached - Very shy – not married Intelligent (academic) Easily setback by minor events Hypersensitive to criticism Feelings of being defective Submissive, easily led Religious Don’t take risks Socially awkward, posture is stiff, clumsy

Therapy

Psychodynamic Pharmacotherapy Group Therapy Interpersonal Therapy Cognitive-Behavioral Therapy

Psychodynamic

Supportive Nonconfrontational Help them understand their

“escapes” Verbalize feelings (instead of

avoiding)

Psychodynamic

Central dynamic is shame Don’t live up to an internal standard

Result: feeling bad Early imprinting, carries into adulthood They adopt a façade (mask) Avoid painful emotions, thoughts

Alcohol abuse

Psychodynamic Two types of avoidants

Type A – temperamentally overanxiousVaried attachment history

Type B – narcissistically vulnerableShaming experiences, faulty

attachment

Psychodynamic Transference Reactions

Fears of relationship Anxious about being transparent Therapist is an expert (i.e., superior) Tend to be very pleasing

Countertransference Reactions Give too much advice Get frustrated because of lack of progress

Psychodynamic

Empathy and support Don’t make unrealistic promises Check for substance abuse Encourage clients to be more

active

Pharmacotherapy

Anxiolytics MAOIs Tricyclics Buspar Beta-blockers SSRIs (Prozac) SNRIs (Effexor)

Group Therapy

Can be ideal group members Therapist needs to protect AVD But difficulty with public speaking Smaller groups work better

0

30

60

90

120

150

180

210

240

270

300

330

0 11 SDFPAR

AVD

HIS

DEPSZD

ANT

NAR

Assured-Dominance

Unassured-Submissive

Warm-Agreeable

Cold-Hearted

Gregarious-Extraverted

Unassuming-Ingenuous

Aloof-Introverted

Arrogant-Calculating

T1 = therapist position start

C = avoidant client

T2 = therapist position end of therapy

Treatment of Social Phobia Treatment CBT

Rapee premised on

Aaron Beck’s work

Step 1: Self-monitoring person keeps via journal for one week

or two

record called social situations record (situation / my thoughts / anxiety /

physical reaction / avoidance)

process is educational for client

Step 2: Realistic Thinking educate client about CBT model

Situation Thoughts Feelings

What is the evidence?What is the probability?Alternative interpretations?

LaughingAt me

Step 2: Realistic Thinking

Situation Thoughts Feelings

Alternative interpretations?

LaughingAt me

Joke?

So what.

Did I do anything?

Step 3: Graded Exposure

put self in actual situations start with low-anxiety situations have client test-out realistic

thinking

truth of situation may be different from perceived situation

Cognitive Therapy

Cognitive Beliefs automatic thoughts distortions

Cognitive View

AutomaticThoughts

EventsSchema

EmotionsBehavior

Others’Behavior

Distortions

“A look”

“They think I am no good” Mind Reading

Anxiety, FearVisible nervousnessAvoidanceOdd reactions

Closer observationDistance

I am defective, others are superior

Catastrophizing

Shame, embarrassment

Anger – Types Bs

Other considerations

• AVD probably criticized in family of origin

• AVD remains loyal to the family– “Family is good, I am defective”

• “Family secrets” remained buried

• Get client to discuss these secrets– Family is good and bad, as am I

Other considerations• “Relationship Issues”

– don’t trust others, fear being shamed, ridiculed– Approach-avoidance conflicts

• Love at a distance – fantasy– Associate with an individual that is unavailable

• Women – romantic comedies• Men – porn and “other avenues”

• Probably lack dating syntax

• “The High Bar”– “I will only date a particular person with particular characteristics– Once I find this person, we will get married.

Towards DSM V

• Current

• 10 PDs

• DSM-V

• 5 PDs• 6 broad traits• 37 Specific traits

Towards DSM 5

• The 5 that might survive…

• Schizotypal

• Antisocial/Psychopathic

• Compulsive

• Borderline

• Avoidant

6 Broad Traits

• Negative Emotionality (high N)

• Introversion (Low E)

• Antagonism (Low A)

• Disinhibition (Low C)

• Compulsivity (High C)

• Schizotypy (?)

DSM-V

• Avoidant PD to Avoidant Type - Rated on 5 point scale

• Trait Ratings - Rated on a 4 point scale• Negative Emotionality (5 areas)

– Anxious, separation anxiety, pessimism, low self-esteem, guilt/shame

• Introversion (5 areas)– Intimacy avoidance, social withdrawal, affective restriction,

anhedonia, social detachment

• Compulsivity (1 area)– Risk aversion

Zelig

Zelig at the movies

Part I Part II Part III Part IV Part V Part VI

Part VII Part VIII Part IX