Avoidant PD

[mistafab]

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Have had a handful of cases in my time so far.

Fundamentally, I am having difficulty helping them.

I am viewing my role primarily as assessment/diagnosis, psychoeducating - providing prognostication. If they accept the diagnosis, connect them with further steps (intensive personality focused psychotherapy, preferably psychoanalysis).

I am wondering if there is anything else I can do as the psychiatrist to assist in these cases? Of my 4 cases thus far, 2 continued to do very, very poorly - one did poorly, and one did well. The person that did well engaged in psychoanalysis and fundamentally wanted to change her life systems to improve her QOL.

What can I do different?

 

[Sushirolls]

I'm not seeing anything different you can do.

I've seen similar number, too. Most just stop showing up to appointments.

 

[comp1]

I know that people describe narcissistic and OCPD as more common, but I have a suspicion that avoidant is much more common than all of them, just not seen clinically or reported in surveys. The issue is that other personality disorders create external pressure on someone to address their maladaptive coping. In fact, that external pressure is the only way you can treat narcissistic PD. Avoidant PD creates no such pressure and in fact, actively avoids its creation. I mean I can conceptualize something where a young adult is too anxious to start a job and parents create external pressure, but the external pressure is usually nothing like other PDs. Ultimately even skilled psychotherapists have many, if not most, patients leave during treatment for avoidant PD. The typical advice is to turn on your own hypervigilance regarding shaming. This is hard because the patient's concept of what you're saying and what your own or a typical understanding would be are likely world's apart. Every word is going to be under a microscope during and between appointments. I do think psychopharmacology has a huge role here given the challenges with psychotherapy. Pills are relatively incapable of rejecting you, although there are psychodynamics with medications of course too. In addition to vulnerable narcissist, the more practical conceptualization of avoidant PD is an extremely pervasive, disabling and long term social anxiety. We have meds for that and the patients should generally be on a SSRI with possible other adjunctive medications.

 

[Stagg737]

I’ve had a few Avoidant PD patients who have done fairly well. The common string was they all really wanted greater socialization and had good insight that their avoidance was actively harmful. I did a little MI with one or two to help them consciously connect those dots, but the underlying motivation was there. I think if you’re good at MI you may be able to make solid headway for some of these patients, especially if they’re distressed.

That said, if their comfort in avoidance is great enough or they don’t care that much, I agree the prognosis isn’t going to be great and I’ve also had a few who just didn’t want to continue care. I also think technology and the ability to easily have pseudo-socialization likely impedes this significantly more today, especially after COVID when “social distancing“ was not only acceptable, but encouraged.

 

[smalltownpsych]

Interesting that the base rate in outpatient is about 15%. I typically have not diagnosed it and tend to diagnose GAD. Thinking about it now, part of the differential is probably the patients who come back and engage in therapy have GAD and the ones who ghost me have Avoidant PD. Leads to a bit of a skewed experience. It does make me think that I should develop some more skill or awareness around this disorder. In other words, if I was to identify and diagnose it more clearly, then perhaps that would improve the outcome.
A quick glance at the literature, it seems I’m already doing what needs to be done to maximize engagement, but I would think that more intentionality would help. Also, often we feel the pressure to “help” or alleviate the presenting distress or fix the problem, and I’m pretty good at slowing that roll and getting to the dialectic of acceptance vs change, but in this population I need to recognize that is even more important and is in essence the treatment itself.