Avoidant Personality Disorder Treatment
Individuals with avoidant personality disorder (AVPD) experience “a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation,” according to the DSM-5.
In a recent study on individuals living with AVPD in the Journal of Clinical Psychology, participants described having to wear a mask for social situations and having a hard time feeling “normal.” For example, one participant shared: “I have never felt seen. Not even my mother knew me like that. I know I have missed it. I never felt loved.”
Participants reported dreading getting emotionally close to others. Another participant noted, “I am very, very suspicious of people. Not that they would harm me physically, but what are their intentions? Or they seem nice, but really, they are not.”
Participants with AVPD also struggled with making sense of their profound insecurities. According to another participant, “There is always something grinding in my head, so there is no rest. I do not know how to answer myself to make it better.”
AVPD is one of the most prevalent personality disorders—and one of the most impairing.
AVPD often co-occurs with social anxiety disorder, along with other anxiety disorders. It also commonly co-occurs with depression and other personality disorders, including dependent personality disorder.
The research on AVPD is scarce. However, psychotherapy has been shown to be effective, and individuals with AVPD do get better. Medication may be helpful, though recommendations mainly stem from research on social anxiety disorder.
There’s a paucity of research on psychotherapy for avoidant personality disorder (AVPD). What is available points to several promising treatments—cognitive behavioral therapy and schema therapy—but there are no clear-cut, definitive recommendations.
In cognitive behavioral therapy (CBT), individuals with AVPD learn to identify their inaccurate, unhelpful cognitions and core beliefs and develop healthier, more adaptive ones. For instance, a therapist helps the individual explore and challenge beliefs about their inadequacy and inferiority and others’ willingness to criticize and reject them.
Another element of CBT is participating in behavioral experiments that challenge individuals’ safety behaviors (e.g., not holding a cup in front of their boss because they worry they’ll be rejected for visibly shaking).
CBT also can include social skills training, which teaches individuals effective ways to navigate social situations and cultivate interpersonal relationships. For instance, individuals with AVPD might learn and practice everything from making appropriate eye contact to asking someone on a date.
Schema therapy (ST) employs a range of techniques, including interpersonal, cognitive, behavioral, and experiential. It’s based on the theory that individuals with personality disorders have various pervasive, maladaptive belief systems and coping styles, which originated from childhood. ST aims to heal and change these “schema modes.”
According to a 2016 review article in Current Psychiatry Reports:
“In treating AVPD, the most relevant schema modes are the Lonely Child mode which is characterized by feelings of loneliness, unworthiness and being unloved, the Avoidant Protector mode, in which situational avoidance is activated, and the Detached Protector mode which is characterized by avoidance of inner needs, emotions and emotional contact. Furthermore, a Punitive Parent mode is active in which the feeling that oneself deserves punishment or blame is assumed to be activated.”
ST also emphasizes the therapeutic relationship, and uses limited re-parenting. According to Bamelis and colleagues, this is when the therapist “partly meets unmet childhood needs within healthy therapy boundaries (e.g., offers safe attachment, praises the patient, stimulates playfulness, and sets limits).”
Recently, researchers concluded a study on the effectiveness of group schema therapy (GST) versus group cognitive behavioral therapy (GCBT) in individuals with social anxiety disorder and avoidant personality disorder. Individuals receiving either GST or GCBT had 30 weekly 90-minute group sessions (along with two individual sessions).
According to the authors, “The ultimate goal of GST is to enable patients to get their emotional needs met, including gaining autonomy and forming healthy social relationships. In GST, the group is used as an analogue for the family of origin with the other group members as ’siblings’ and the therapists as ‘parents.’”
In GCBT, participants write down a list of feared situations (in order of most to least feared). Next, they gradually and systematically confront these feared situations in therapy and outside of session. They also learn to challenge and change their negative, unhelpful thoughts.
The study results haven’t been published yet.
Research on medication for avoidant personality disorder (AVPD) is virtually nonexistent. Most of the data derives from studies on social anxiety disorder. Currently, no medication has been approved by the U.S. Food and Drug Administration to treat AVPD, so medication is prescribed “off label” (a common practice with other disorders, as well).
In 2007, the World Federation of Societies of Biological Psychiatry (WFSBP) issued guidelines recommending selective serotonin reuptake inhibitors (SSRIs) as the first-line treatment for AVPD. The authors noted their decision came from the demonstrated efficacy of a number of SSRIs and their “relatively benign side effect profile,” which they listed as: “nausea, dry mouth, constipation, sexual dysfunction, agitation, paraesthesia, tiredness; very low rate of severe cardiovascular and cerebrovascular adverse reactions, low rates of gastrointestinal bleeding or diabetes insipidus.”
The WFSBP also recommended the serotonin norepinephrine reuptake inhibitor (SNRI) venlafaxine as a first-line treatment for AVPD.
Benzodiazepines were not recommended for AVPD because of their potential for abuse and dependence.
SSRIs or an SNRI may be prescribed for co-occurring conditions, such as depression or an anxiety disorder.
In sum, medication may be helpful for treating symptoms and other psychological disorders. But research hasn’t specifically explored AVPD (and should), and psychotherapy needs to be the main intervention.
The best way to effectively treat avoidant personality disorder (AVPD) is to seek therapy. The below strategies can complement professional treatment (and may be easier or more difficult depending on the severity of symptoms):
Practice compassionate self-care. Engaging in healthy habits gives you the energy and fuel to tackle difficult situations and challenging lessons in therapy. For instance, focus on getting enough sleep, and incorporating nutrient-rich foods into your diet. Engage in physical activities you enjoy. Exercise helps you to feel empowered, reduces stress and anxiety, and boosts mood. Also, focus on pursuing hobbies that contribute to your life in a meaningful way—which can include easing into interactions with people who share your passions.
Take small steps. Identify several small ways that you’d like to connect with others, such as initiating a conversation or sending a thank-you email. Make a list of these ideas, and try to tackle one each day or each week.
Learn assertiveness skills. Being assertive is a skill that you can learn and master with practice. You can learn to say no, ask for what you need, and set boundaries to create healthy interactions and relationships.
Being assertive starts with identifying your values and your needs, and trying out your skills in less intimidating situations. It also can help to shift your mindset, such as pretending the person you’re speaking to is your employee or even wearing a clown nose or funny costume (you’ll find the details and more tips here).
Consider immersing yourself in the topic by reading books on assertiveness, such as The Guide to Compassionate Assertiveness, 5 Steps to Assertiveness, and The Assertiveness Guide for Women. If you have a close friend you feel comfortable with, consider asking them to role-play with you.
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