Treating Avoidant Personality Disorder

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.

Sometimes this method works. Sometimes it's the only method that will work, but often, a shorter, more emotionally and financially economic approach can be helpful as a treatment option or a supplement to ongoing therapy.

In the case of the bookkeeper, the plan was for me to consult, provide a treatment strategy, and send him back to the referring psychiatrist. It was not necessary to use every facet of my learning, philosophizing, and action (LPA) technique, which has been so effective in my work.

The reason is that he had learned and philosophized a great deal therapeutically with his original psychiatrist. My job was to offer a new perspective and technique to help him attain additional goals. Focusing on the action part of the LPA technique alone was the planned approach.

In the first visit, I took my own history, including the patient's therapeutic gains and what his goals were in seeing me. His goals specific: going to a gym and getting involved in hiking. I explained that I was going to teach him some relaxation therapy techniques, coupled with behavior modification. I taught him a relaxation technique during the first visit.

I told him to use the eye-roll, deep breathing method, which can be learned quickly and practiced at home. The plan was for him to practice this technique and return in 2 weeks after he picked up some brochures about the gym and a picture book on hiking. When the patient returned, he and I looked at the brochures and the book. We fixated on several good images in both.

From there I asked the patient to sit back, relax, and let himself go into the relaxation technique that I had taught him 2 weeks earlier and that he had practiced. He was quite good at it, as I remember, although he thought he didn't do it well.

Indeed. He invoked the name of his psychiatrist, saying that Dr. So and So would not go for that negative response. He actually quickly reversed this and sort of knew he was OK at the technique. While he went into a good relaxed state, I had him use that favorite technique of mine—imagining a great big movie screen. It is at that point when relaxation begins to reciprocally inhibit the mental mechanisms that help decrease the focus on avoidance, just as it does in anxiety disorders.

At this point, we added in vitro systematic desensitization by having the patient see himself on the screen in the gym working out or on a trail hiking. As the patient sees himself on the screen he may want to avoid the scene, but if he switches to see himself as part of a gym photo, where he is on the treadmill or stair master, he can start to be a participant in what he wants to be doing. Albeit this is in vitro, but it's how the desensitization begins.

Nevertheless, with an additional 1.5 hours of practicing, the patient began to feel very comfortable with these visualizations. The next visit would be 2 weeks later, with his out-of-office experience with the gym and his plans for the hiking hobby that he so much wanted. We did have a third visit, and the patient had not avoided going to the gym. During that visit, he imagined himself in a pleasant, even happy scene, such as that illustrated in the brochure about the gym that was now part of his in vitro imagery with him in it.

He was looking into hiking clubs that he might be able to join. The patient did return to his ongoing psychotherapy with the first psychiatrist, who continued to be committed to his own type of care as well as the short-term behavior modification approach I used.

Did this patient really need 3 years to attain a method to solve his personality problem? Or would a 3- to 6-month period of cognitive therapy and relaxation behavior modification have done the job? I don't have the answers, but if more clinicians knew how to standardize a diagnosis and work with shorter goal-oriented therapies, a great emotional and financial burden would be lifted from the patient population.

Let me know what you think about the challenging diagnosis and treatment of avoidant personality disorder, and I will try to pass your ideas along to my readers.