Magazine article Clinical Psychiatry News

Treating Avoidant Personality Disorder

Magazine article Clinical Psychiatry News

Treating Avoidant Personality Disorder

Article excerpt

One of the most challenging people I've treated was a man in his 40s who had lived a lonely, isolated life as a bookkeeper for a large textile firm.

He had his own private office--which allowed him to keep socialization with coworkers to an absolute minimum--and essentially overproduced with an ongoing fear that he would not do a proper job, despite his 20-year tenure with the firm.

He loved being physically fit, and his dream was to become good at hiking. The patient belonged to a gym but never went because he believed people would laugh at his lack of muscles. He read hiking books but never hiked because he did not believe he could do it successfully.

After 3 years of weekly psychotherapy, this patient got a better understanding about the problems of rejection and critical analysis that had marked his upbringing. He liked his psychiatrist, but he wanted a way to turn his new more positive thoughts into a better lifestyle. His psychiatrist, whom I knew, referred the patient to me for specific behavior modification techniques aimed at moving the patient in the direction the patient wanted.

As we well know, some people are shy. Others are so shy that they actually avoid one situation after another. We encounter these patients through self-referral, assignment, referral from their primary care physicians, or referral from other psychiatrists or mental health professionals. The latter kind of referral was often the case in my short-term therapy practice.

Patients referred from other mental health professionals often came to me because their therapy, usually supportive as well as insight-oriented, was not working optimally and they were searching for a method to complement their ongoing psychotherapy.

This was the situation with the patient who had the avoidant personality disorder. The differential diagnosis apparently goes beyond shyness, and reticence can easily be confused with social phobia ("Is Social Phobia a Disorder or Not," The Psychiatrist's Toolbox, February 2007, p. 16), agoraphobia, and even schizoid personality disorder--more often diagnosed in Europe with ICD classifications.

Although we have some good standards for diagnosing those with avoidant personality disorder, it again comes down to inference, subjectivity, and a clinician's particular school of thought. Of course, it also comes down to the overlap with social and agoraphobic disorders and with the schizoid personality disorder, which many European psychiatrists see more as a part of the continuum in the schizophrenias.

Some of the dominant thoughts in people with avoidant personality disorders center around decreased self-esteem, negative analysis of their own worth in social or vocational situations, and a subsequent avoidance of situations where they will be in the forefront.

Cognitive therapeutic formulations explain these people in terms of the negativity of their automatic thoughts and therefore aim to develop challenges to these thinking patterns. Some of the early thoughts on avoidant personality styles came 60-plus years ago with Dr. Karen Horney, who recognized people who chronically avoided life situations and for whom isolation became a way of life. Of course, codification in those days was not a high priority in psychiatry or psychology. What Dr. Horney saw and evaluated may have been a group of disorders that centered on avoiding situations, rather than true cases of avoidant personalities.

Today, we do better with the codification process, but overlap and subjectivity still dominate clinical evaluation, and of course, continue to influence treatments and treatment outcomes.

Again, my referrals came from good therapists using insight-oriented psychotherapy that was aimed at helping patients gain an understanding of the interpersonal origins of their avoidance and subsequent unhappiness with their isolative, negative thoughts and behaviors. …

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