Avoidant Personality Disorder

Avoidant Personality Disorder is a pervasive pattern of social inhibition, feelings of inadequacy, and extreme sensitivity to negative evaluation that begins in early adulthood and occurs in a variety of contexts. The diagnosis is characterized by at least four of seven criteria of social avoidance and withdrawal. Avoidant Personality Disorder must be differentiated from the axis one diagnosis of Social Phobia. The DSM noted that there is a great deal of overlap, so much so that Social Phobia and Avoidant Personality Disorder may be an alternative conception of the same condition. In Avoidant Personality Disorder however, there is early onset, no clear precipitants, and a stable course. This diagnosis developed out of Millon’s “active-detached” pattern of character functioning.

There are similarities between schizoid personality and Avoidant Personality Disorder. However, individuals with schizoid personality do not desire social relationships and those with avoidant personality avoid relationships because of fears of negative evaluation. Social Phobia usually involves specific fears related to social performance rather than the more pervasive pattern of functioning that is described by avoidant personality.

Those individuals afflicted with Avoidant Personality Disorder are difficult to engage in treatment because of their significant fears of rejection. Techniques of supportive and empathic understanding and tolerance for lack of change are important. Theoretical orientations include Cognitive behavioral, supportive and psychodynamic. The best approach is to use supportive techniques at first, then slowly move to more directive or interpretive approaches.

You will need to conduct an assessment and establish a working relationship. When doing the assessment be sure to get a thorough clinical history as well as a psychosocial and assess safety issues. You may need to refer to a psychiatrist for possible psychotropic medication. You should also refer to a physician to see if there is any medical cause for the symptoms.

Finally, you should discuss the diagnosis with the patient and make agreements for treatment. Since others are less affected by the concerns of the patient, their feelings of worry may be discounted. It can be freeing for an individual to listen and “get inside” the patients worry and not rationalize away the fears and concerns. After a rapport is developed, you may slowly begin to confront avoidant behaviors and develop appropriate goals for social interaction. It may be appropriate to work on issues of grief and loss as these individuals often avoid social interaction due to past losses and fear of future losses. The development of future coping mechanisms is vital as is improving self-esteem. For CT therapy, one may develop a plan that includes systematic desensitization to reduce anxiety and cognitive restructuring to change distorted beliefs.

Working with these individuals is a long and difficult process, however, some change may occur in short-term treatment. Most important is developing a solid therapeutic relationship that will encourage future treatment when needed. For short-term treatment, consider it serial treatment with small steps at a time.

Group therapy may be useful to encourage social skills and interaction. However, it is difficult to engage these folks in individual treatment, much less group. Anxiolyitics may be helpful in the short term to reduce avoidant behavior and encourage new learning while in therapy.