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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
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
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