Avoidant Personality Disorder Treatment
Suzanne M. Sutherland, M.D.
In formulating guidelines for the treatment of avoidant personality disorder, it is important to bear in mind that this disorder shares many similarities with the Axis I disorder social phobia, as well as with agoraphobia. Avoidant personality disorder also shares characteristics with other Axis II disorders, particularly dependent personality disorder (Brooks et al. 1989; Widiger 1992). When appropriate treatment is being considered for any individual, the overlapping traits must be taken into account in order to define a specific treatment plan that is appropriate for that individual.
In applying any of these therapies, the clinician should bear in mind two important issues. First, patients with avoidant personality disorder are particularly sensitive to scrutiny, even in a therapy situation. They may be reluctant to openly express their internal experience for fear of criticism from the therapist and also for fear of embarrassment. The first and most immediate goal of therapy should be to establish the rapport necessary for these patients to be able to make a commitment to a course of treatment. If this is not successful, the patient is not likely to return for a second visit. Second, clinicians must determine the length of treatment necessary for the patient to become fully functional. Clinical experience suggests that most therapies require at least a year before the avoidance is no longer significantly maladaptive, even though there may be noticeable improvement in functioning before that. The following paragraphs address the various specific therapies that can be useful in the treatment of avoidant personality disorder once a therapeutic alliance has been established.
Cognitive and Behavior Therapies
Any of several behavior therapies can be effective treatments for social anxiety and avoidant behaviors. These include CBT, rational-emotive therapy, systematic desensitization, and social skills training, in conjunction with exposure techniques, either graduated or flooding. In addition, anxiety management techniques should be provided early in therapy because these patients will predictably begin to experience elevated levels of anxiety as their exposure to feared situations increases during the course of therapy.
Treatment gains may not be impressive immediately after a period of therapy but may become evident after a longer period of exposure to avoidant situations. It may not always be necessary to engage in ongoing therapy after the initial treatment course. Follow-up data have suggested that some patients maintain gains and even improve on some measures several months to years after completing the treatment course (Emmelkamp et al. 1985; Heimberg et al. 1990; Mersch et al. 1991). However, the few data available suggest that for more severely impaired patients, additional treatment is indicated after a brief treatment course (Mersch et al. 1991).
Socially avoidant persons, although improving significantly after behavioral treatments, tend to show limitations in the amount of improvement and may not reach "normal" levels of functioning after treatment (Alden 1989; Cappe and Alden 1986). Stravynski et al. (1982) reported significant improvement on treatment targets for both the social skills training and the cognitive restructuring groups but noted the lack of generalization to in vivo intimate relationships at a 6-month follow-up and suggested the need for some form of intimacy training. In light of this finding, it may be important for many patients with avoidant personality disorder to engage in psychodynamic therapy and/or IPT (see below), either as a primary treatment or as an adjunct to a cognitive-behavioral approach.
The treating clinician also should bear in mind that the internal cognitions of the patient receiving treatment will affect that patient's assessment of any exposure experience and will determine whether the exposure is desensitizing or whether it may be an experience that further reinforces negative cognitions. This is one interpretation of those studies in which long-term follow-up indicated relapse after exposure therapy alone but maintenance and enhancement of gains after CBT.
Typical cognitions of patients with avoidant personality disorder include self-deprecating thoughts such as "I am a social failure" and "Every time I open my mouth, I say something stupid" or "I am a fraud—if I talk freely to others, they will figure out that I'm really not qualified." A second major area is these patients' expectation that others will assess them negatively and will reject them. They may think, for example, "People will think I am bragging if I talk about what I know or if I mention the recognition I have received," and "Nobody wants to be around someone as boring as me" or "I am sure they won't like me." The third major area of distorted cognition in patients with avoidant personality disorder is the belief that unpleasant thoughts and feelings are unbearable. These persons may think "I can't handle feeling this sad" or "I'll lose control if I let myself feel this bad."
The goal of cognitive therapy should be to alter the patient's self-critical cognitions and expectations of critical assessment by others and to challenge the common belief that any unpleasant emotion or interaction is intolerable. If the patient's tendency to negatively interpret social interactions has been addressed in therapy, then the exposure experiences can positively alter the patient's overall assessment of his or her experience in the world.
Interpretive techniques may be useful either alone or as adjunctive interventions with behavior and exposure therapies. An "uncovering" approach may be used to interpret the unconscious fantasies related to the patient's fear that he or she will lose control of his or her behavior, resulting in criticism from others and causing the patient to feel threatened, shamed, or embarrassed. Patients with avoidant personality disorder are likely to have harsh superegos and also to project their unrealistic expectations of themselves onto others. They avoid interpersonal relationships in order to evade expected criticism and embarrassment.
Gabbard (1994) pointed out that the psychodynamic meaning of the anxiety must be explored in order to understand its origins in the individual patient and that shame is often uncovered as a central affective experience. In the typical patient, shame and self-exposure are intimately connected, and the patient actively withdraws from interpersonal situations in order to avoid experiencing the highly unpleasant affect of shame. Earlier psychoanalytic writings stressed the importance of identifying the unconscious impulse (sexual, aggressive, or dependent) and the fear and guilt it evokes and then tracing the ensuing avoidant defensive pattern in the transference, in outside relationships, and in early life experiences (Fenichel 1945). Patients with avoidant personality disorder may be excellent candidates for various types of psychodynamic treatment, including focal, long-term, and even psychoanalytic treatment. The combination of psychodynamic and exposure therapies can be particularly useful. A psychodynamic approach can be helpful in dealing with issues of shame, guilt, and grief that may arise during the course of CBT, as well as during pharmacotherapy; exposure can increase the usefulness and pertinence of the uncovering enterprise.
IPT attempts to provide patients with a healing interpersonal or corrective emotional experience in the therapeutic relationship. This experience may allow them to take chances in this interpersonal relationship that they have been unwilling to take in their lives. As they overcome their fear of interpersonal rejection within the therapeutic setting, these patients can learn to take additional chances outside the treatment, where they may also discover that their behavior is acceptable. Interactional psychotherapy in this context is a treatment in which the patient's maladaptive behavior is dealt with directly in the context of the therapist-patient relationship (Cashdan 1982).
In IPT, the therapist first uses supportive techniques to overcome the patient's timidity and avoidance. As the patient becomes more secure in the treatment relationship, the therapist maintains a sympathetic and protective attitude while directly encouraging assertive behavior. As therapy progresses and the patient becomes more self-confident, the therapist becomes less supportive of the avoidant behavior and withholds the sympathy and protection (Cashdan 1982). The therapist also may bring in significant others or work in a group format in which the patient can actively try out new behaviors.
There is as yet no compelling evidence for recommending medication as a primary form of treatment of avoidant personality disorder. However, the evidence that several medications are effective in the treatment of generalized social phobia has implications for the utility of these medications in treating avoidant personality disorder. When treatment possibilities are being considered for a patient with avoidant personality disorder, the pattern of heightened psychic pain and diminished psychic pleasure that Millon (1996) described as being at the heart of avoidant personality disorder must be recognized. Although many patients with avoidant personality disorder may engage in such global avoidant behavior that they do not experience the typical physiological symptoms of social anxiety, such as palpitations, blushing, tremor, and sweating, the internal experience of emotional pain may be severe and may be alleviated somewhat with medication. Also, pharmacotherapy, particularly with MAOIs and SSRIs, may affect some of the core dimensional features of avoidant personality disorder, such as shyness, rejection sensitivity, heightened psychic pain, and distorted cognitions related to self-criticism and self-effacement.
For those patients nonresponsive to the above-mentioned antidepressants, the newer agent venlafaxine may be helpful. Data are also emerging in support of other agents with anxiolytic and mood-stabilizing properties, which may be used alone or in conjunction with an antidepressant. The high-potency benzodiazepine clonazepam has been shown to be effective for generalized social phobia, and recent data indicated little difficulty in withdrawal after months of treatment (Connor et al. 1998). The clinician should balance the issue of possible substance dependence with findings that patients with generalized social phobia and panic disorder tend to require lower doses or to become drug-free over time (Davidson et al. 1991; Rickels et al. 1993).
The well-tolerated anticonvulsant gabapentin also may be useful. In a two-center trial of outpatients with DSM-IV social phobia, the benefits were most apparent in those patients with more severe symptoms and with agoraphobic features (Pande et al. 1999).
The patients may need frequent visits for support during the minimum 6-week trial period for medication, and encouragement from the clinician is generally necessary for the patient to initiate changes in behavior. Exposure to avoided situations is critical to the healing process, as well as a course of drug treatment that is at least several months' duration.
Group therapy can be extremely beneficial, although particularly anxiety-provoking for patients with avoidant personality disorder, and is recommended after a period of individual treatment. Individual cognitive therapy in preparation can improve the likelihood of participation in group therapy and also will allow the individual to make better use of this modality. New attitudes and skills can then be learned in a benign and accepting social environment. Group treatment can also serve as a corrective emotional experience that may allow the patient to pursue intimate relationships outside the therapy setting. A group that is psychodynamically oriented also may provide valuable empathic support and appreciation of the courage needed for these patients to expose themselves to social situations. It can provide the positive experience that these patients may find necessary before they are willing to apply newly learned behaviors to in vivo situations.
It is common for the avoidant behavior of the patient with avoidant personality disorder to be reinforced by a family context that is analogous to the workings of the phobic partnerships formed by patients with Axis I agoraphobia. Family members may become overprotective with the intent of being helpful but in fact may help to maintain the patient's unwillingness to take chances (Carson 1982; Kiesler 1982). The clinician may find it useful to engage family members in the treatment process by educating them about the importance of behavior changes in the patient. Family members may become extremely helpful in encouraging the patient to engage in social situations and also may be able to give emotional support while prodding the patient to seek out new experiences.
For individuals with AvPD, drugs and alcohol provide escape/avoidance of painful feelings and the situations that elicit these feelings. Drug use assists in modulating hyperarousal and self-deprecatory thoughts. Some individuals with AvPD prefer mild hallucinogens over other drugs, perhaps because they facilitate fantasy. However, sedatives and antianxiety agents are usually the drugs of choice for most clients with AvPD (Richards, 1993, p. 269). While sedative-hypnotics calm anxiety, stimulants or PCP can provide a sense of strength or reduced vulnerability. The drug of choice for these individuals will be whatever gives them a sense of efficacy or allows them to believe that they can be attractive and effective interpersonally.
Many individuals with AvPD also develop compulsive behaviors that relate to appearance enhancement, fantasy, and self-comfort. They may enter treatment with compulsive shopping, compulsive sexual behaviors, and eating disorders in place as well as with drug or alcohol addiction. Abstinence, to be effective, will need to address all self-destructive behaviors as well as drug and alcohol use.
Avoidant personality disorder is a disorder that is being increasingly recognized as one that is fairly prevalent and that causes much impairment in both social and occupational functioning. Although some initial treatment data show some improvement with the various forms of treatment described here, the small body of literature does not enable us to make a conclusive statement regarding a definitive form of treatment. However, there is growing optimism that this personality disorder may be highly treatable with good long-term prognosis. Clearly, this disorder warrants further research, including further study of its management with CBT and medication, alone and in combination. Finally, all of these therapies need to be evaluated in the various formats of individual, group, and family therapy.
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