The treatment of avoidant personality disorder by social skills training in the clinic or in real-life settings

Examining the relationship between social withdrawal motivations and symptoms of hikikomori

Objective: This study aimed to examine the association between social withdrawal motivations (peer isolation, shyness, unsociability, low mood, and avoidance) and symptoms of hikikomori using both variable- and person-oriented analyses.Method: Adolescents (N = 212) participated in this cross-sectional study. Data were collected using the Social Withdrawal Motivations Scale and the Avoidance subscale of the Child Social Preference Scale-Revised, the 25-item Hikikomori Questionnaire, the Personality Inventory for the DSM-5 Brief Form, and the Interpersonal sensitivity subscale of the Brief Symptom Inventory.Results: Path analysis revealed that peer isolation, shyness, unsociability, and avoidance were associated with symptoms of hikikomori while covarying for age, sex, maladaptive personality, and interpersonal sensitivity. Cluster analysis based on social withdrawal motivations identified four subtypes of adolescents. The group with high social withdrawal motivations showed the highest level of overall personality dysfunction and interpersonal sensitivity. Additionally, the group with high social withdrawal motivations and the group with high avoidance demonstrated higher symptoms of hikikomori compared to the other two groups, after accounting for the effects of the covariates.Conclusions: The findings highlight that the evaluation of co-occurrent social withdrawal motivations may improve the ability to identify those adolescents most in need of support.

Comparison of Cognitive Behavioral Therapy and Cognitive Behavioral Group Therapy in the Treatment of Avoidant Personality Disorder

The primary aim of this study is to compile studies on cognitive behavioral therapy method in the treatment of avoidant personality disorder and present their data. Another aim is to discuss with the reasons, cognitive behavior group therapies may be more effective on this disorder than cognitive behavioral individual therapies, since the main problem in avoidant personality disorder stems from interpersonal communication and because the cognitive behavioral therapies applied as a group were found to be quite effective when the avoidant personality disorder was first defined. The aim of this study is to present recommendations together and to compile studies in which cognitive behavioral group therapies were applied on avoidant personality disorder. In this study, studies in domestic and foreign sources, which were conducted with a sample group with avoidant personality disorder and social anxiety disorder, were examined and the study was prepared by reviewing the literature, which is one of the secondary data collection techniques. Since there are not many studies on avoidant personality disorder in the literature, considering the high similarity and comorbidity of avoidant personality disorder with social anxiety disorder, studies on cognitive behavioral group therapies related to social anxiety disorder have also been compiled. As a result of the studies examined, it has been found that the symptoms of avoidant personality disorder are related to the distorted cognition of individuals and cognitive behavioral therapies are a very effective approach because they increase the awareness of the automatic thoughts in the minds of the clients, question their correctness and provide alternative thoughts to replace them.

Combined group and individual therapy for patients with avoidant personality disorder-A pilot study

Objective

Avoidant personality disorder (AvPD) is a common disorder within mental health services, associated with significant psychosocial impairment. The disorder has been neglected in research. There are currently no evidence-based treatments for AvPD, and there is a need for treatment studies focusing particularly on this form of personality pathology. The present study was a pilot study of combined group and individual therapy for patients with AvPD, based on mentalization-based and metacognitive interpersonal therapy. The aim was to investigate the feasibility of the treatment program and the course of symptoms and personality functioning during treatment and 1-year follow-up.

Methods

The study included 28 patients. Clinical evaluation at baseline comprised structured diagnostic interviews and patients' self-report of symptoms, psychosocial function, interpersonal problems, personality functioning, alexithymia, self-esteem, attachment style, therapeutic alliance, and client satisfaction. Patients' self-report were repeated at the end of treatment and 1-year follow-up.

Results

The drop-out rate was 14%. Average treatment length among the 22 treatment completers was 17 months. Mean levels of therapeutic alliance and client satisfaction were satisfactory. Effect sizes were large for global symptom distress, depression, anxiety, and psychosocial adjustment, and in the moderate range for aspects of personality functioning. Yet, the results showed a wide range of outcomes among the patients.

Conclusions

This pilot study shows promising results for combined group- and individual therapy for AvPD patients with moderate to severe impairment. Larger scale studies should be conducted to increase empirically based knowledge to guide development of differentiated treatments adapted to patients' various levels of AvPD severity and profiles of personality dysfunction.

Current state of the evidence on community treatments for people with complex emotional needs: a scoping review

BACKGROUND

Improving the quality of care in community settings for people with 'Complex Emotional Needs' (CEN-our preferred working term for services for people with a "personality disorder" diagnosis or comparable needs) is recognised internationally as a priority. Plans to improve care should be rooted as far as possible in evidence. We aimed to take stock of the current state of such evidence, and identify significant gaps through a scoping review of published investigations of outcomes of community-based psychosocial interventions designed for CEN.

METHODS

We conducted a scoping review with systematic searches. We searched six bibliographic databases, including forward and backward citation searching, and reference searching of relevant systematic reviews. We included studies using quantitative methods to test for effects on any clinical, social, and functioning outcomes from community-based interventions for people with CEN. The final search was conducted in November 2020.

RESULTS

We included 226 papers in all (210 studies). Little relevant literature was published before 2000. Since then, publications per year and sample sizes have gradually increased, but most studies are relatively small, including many pilot or uncontrolled studies. Most studies focus on symptom and self-harm outcomes of various forms of specialist psychotherapy: most result in outcomes better than from inactive controls and similar to other specialist psychotherapies. We found large evidence gaps. Adaptation and testing of therapies for significant groups (e.g. people with comorbid psychosis, bipolar disorder, post-traumatic stress disorder, or substance misuse; older and younger groups; parents) have for the most part only reached a feasibility testing stage. We found little evidence regarding interventions to improve social aspects of people's lives, peer support, or ways of designing effective services.

CONCLUSIONS

Compared with other longer term mental health problems that significantly impair functioning, the evidence base on how to provide high quality care for people with CEN is very limited. There is good evidence that people with CEN can be helped when specialist therapies are available and when they are able to engage with them. However, a much more methodologically robust and substantial literature addressing a much wider range of research questions is urgently needed to optimise treatment and support across this group.

Treating Avoidant Personality Disorder With Combined Individual Metacognitive Interpersonal Therapy and Group Mentalization-Based Treatment: A Pilot Study

ABSTRACT

Avoidant personality disorder (AvPD) is a severe but understudied condition. The current pilot project reports data on acceptability and outcomes of a novel treatment combining biweekly individual metacognitive interpersonal therapy (MIT) and weekly mentalization-based therapy (MBT) group therapy. A total of 30 patients with AvPD were consecutively included in the program. The primary outcome was AvPD-specific personality functioning measured by self-report after treatment. Secondary outcomes were symptom distress, interpersonal problems, quality of life, and psychosocial functioning. Twenty-two patients completed treatment, with a mean duration of 13 months. On the primary outcome, effect sizes were generally moderate to large (effect size range: 0.59-1.10). On secondary outcomes, effect sizes were large (effect size range: 0.77-2.3). Both in terms of acceptability and outcomes, results are promising for the combination of MIT and MBT for AvPD. The approach is a strong candidate for further investigation in future large-scale randomized controlled trial.

Randomized controlled evaluation of the psychophysiological effects of social support stress management in healthy women

Considering the high and increasing prevalence of stress, approaches to mitigate stress-related biological processes become a matter of public health. Since supportive social interactions contribute substantially to mental and physical health, we set out to develop a social support stress management intervention and examined its effects on psychophysiological stress responses as well as self-reported stress in healthy women. In a parallel-group randomized controlled trial, registered in the DSRK (DRKS00017427), 53 healthy women were randomly assigned to a social support stress management or a waitlist control condition. All participants underwent a standardized psychosocial stress test where physiological and emotional stress responses were assessed by repeated measurements of cortisol, heart rate, heart rate variability and state anxiety. Also, all participants completed self-report questionnaires of perceived stress and social support at pre-intervention, post-intervention and follow-up four weeks later. Participants in the social support stress management showed a significantly attenuated integrated state anxiety response in comparison to those in the control condition, but conditions did not differ in any of the assessed physiological stress responses. The intervention significantly reduced perceived stress in comparison to the control condition, but perceived stress levels returned to baseline at follow-up. Our results indicated that the intervention had no effect on physiological responses to acute psychosocial stress, even though anxiety responses to stress were attenuated. However, the social support stress management intervention had a significant, albeit transient impact on perceived stress.

Avoidant personality disorder: current insights

Avoidant personality disorder (AVPD) is a relatively common disorder that is associated with significant distress, impairment, and disability. It is a chronic disorder with an early age at onset and a lifelong impact. Yet it is underrecognized and poorly studied. Little is known regarding the most effective treatment. The impetus for research into this condition has waxed and waned, possibly due to concerns regarding its distinctiveness from other disorders, especially social anxiety disorder (SAD), schizoid personality disorder, and dependent personality disorder. The prevailing paradigm subscribes to the "severity continuum hypothesis", in which AVPD is viewed essentially as a severe variant of SAD. However, areas of discontinuity have been described, and there is support for retaining AVPD as a distinct diagnostic category. Recent research has focused on the phenomenology of AVPD, factors of possible etiological significance such as early parenting experiences, attachment style, temperament, and cognitive processing. Self-concept, avoidant behavior, early attachments, and attachment style may represent points of difference from SAD that also have relevance to treatment. Additional areas of research not focused specifically on AVPD, including the literature on social cognition as it relates to attachment and personality style, report findings that are promising for future research aimed at better delineating AVPD and informing treatment.

The Short-Term Treatment of a Long-Term Interpersonal Avoidance

This case study presents the 21-session cognitive-behavioral treatment of a young adult female diagnosed with Generalized Social Phobia (GSP) and Avoidant Personality Disorder (APD). Therapy utilized Beck’s modified cognitive therapy of personality disorders in addition to behavioral skills training. Therapist observation, client self-report, and objective measurements were used to assess behavioral change. Postintervention administrations of the Beck Depression Inventory–II (BDI-II), Beck Anxiety Inventory (BAI), and Minnesota Multiphasic Inventory–2 (MMPI-2) evinced a clinically significant reduction of symptoms. The results indicate that a short-term cognitive-behavioral approach may prove efficacious when treating APD.

Frontiers in Cognitive Behaviour Therapy for Personality Disorders

Clinicians generally find individuals with personality disorders to be challenging to treat, especially compared to clients who have only a straightforward depression or anxiety disorder. In this article we will summarise research on the efficacy of cognitive behaviour therapy (CBT) for personality disorders. Then we will focus on the conceptualisation and treatment of CBT for personality disorders that is based on the work of Aaron Beck and colleagues; that is, it is predicated upon the cognitive model of psychopathology. Next, we will describe two other forms of treatment with cognitive behavioural roots: schema therapy and dialectical behaviour therapy. A final section will suggest future directions.

Avoidant Personality Disorder: a Current Review

This review focuses on recent research on diagnostic aspects, etiology, and treatment of avoidant personality disorder (AVPD). Current studies stress the close relation between AVPD and social anxiety disorder, the influence of genetic factors in the development of AVPD, and the relative stability of symptoms. Treatment approaches should target the pervasive patterns of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. Empirical evidence for cognitive-behavior and schema therapy is promising. Few other therapeutic approaches have been developed, but until now, these have only been investigated in case studies. We conclude that AVPD qualifies as a neglected disorder and that more research specifically on avoidant personality disorder symptoms and its treatment is needed.

An Integrative Approach Using Third-Generation Cognitive-Behavioral Therapies for Avoidant Personality Disorder

Evidence-based practice emphasizes the integration of empirically supported treatments with clinical expertise and unique client characteristics. The present study describes an integrative approach using Acceptance and Commitment Therapy (ACT) and skills training adapted from Dialectical Behavior Therapy (DBT) to treat a client with avoidant personality disorder (AvPD), comorbid adjustment disorder, and self-injurious behavior. The process of matching the therapies to the client and specific techniques to symptoms and problem behaviors is described. Ongoing clinical measures indicated reductions in depression, hopelessness, and anxiety. Behavioral measures indicated remission of cutting behavior and increases in social and physical activities. Results from a 1-month follow-up suggested maintenance of gains and continued reduction in symptoms. The Minnesota Multiphasic Personality Inventory–2 (MMPI-2) profile at follow-up as compared with pre-treatment indicated significant decreases in the client’s experience and perception of her symptoms. Endorsements on the Acceptance and Action Questionnaire–II (AAQ-II) at mid-treatment and follow-up suggested that the client achieved greater psychological flexibility. This case serves as evidence that individuals with AvPD and significant symptoms of anxiety and depression can be receptive to, and can benefit from, the integration of third-generation cognitive-behavioral therapies.

Psychotherapy for personality disorders

Personality disorders are widely prevalent among those seeking mental health services, resulting in substantial distress and a heavy burden on public assistance and health resources. We conducted a qualitative review of randomized controlled trials (RCTs) of psychosocial interventions for personality disorders. Articles were identified through searches of electronic databases and classified based on the focus of the psychological intervention. Data regarding treatment, participants and outcomes were identified. We identified 33 RCTs that evaluated the efficacy of various psychosocial treatments. Of these studies, 19 focused on treatment of borderline personality disorder, and suggested that there are several efficacious treatments and one well-established treatment for this disorder. In contrast, only five RCTs examined the efficacy of treatments for Cluster C personality disorders, and no RCTs tested the efficacy of treatments for Cluster A personality disorders. Although other personality disorders, especially Cluster A, place heavy demands on public assistance, and in spite of recommendations that psychosocial interventions should be the first line of treatment for these disorders, our review underscored the dearth of treatment research for many of these personality disorders. We highlight some obstacles to such research and suggest directions for future research.

The effectiveness of cognitive behavioral therapy for personality disorders

This article provides a comprehensive review of cognitive behavioral therapy (CBT) treatments for personality disorders (PDs), including a description of the available treatments and empirical support, drawing on research published between 1980 and 2009. Research generally supports the conclusion that CBT is an effective treatment modality for reducing symptoms and enhancing functional outcomes among patients with PDs, thereby making it a useful framework for clinicians working with patients with PD symptomatology. There is a clear need, however, to develop and evaluate CBT in order to provide specific and more unambiguous treatment recommendations with particular relevance for understudied PDs.

Social anxiety disorder: questions and answers for the DSM-V

BACKGROUND

This review evaluates the DSM-IV criteria of social anxiety disorder (SAD), with a focus on the generalized specifier and alternative specifiers, the considerable overlap between the DSM-IV diagnostic criteria for SAD and avoidant personality disorder, and developmental issues.

METHOD

A literature review was conducted, using the validators provided by the DSM-V Spectrum Study Group. This review presents a number of options and preliminary recommendations to be considered for DSM-V.

RESULTS/CONCLUSIONS

Little supporting evidence was found for the current specifier, generalized SAD. Rather, the symptoms of individuals with SAD appear to fall along a continuum of severity based on the number of fears. Available evidence suggested the utility of a specifier indicating a "predominantly performance" variety of SAD. A specifier based on "fear of showing anxiety symptoms" (e.g., blushing) was considered. However, a tendency to show anxiety symptoms is a core fear in SAD, similar to acting or appearing in a certain way. More research is needed before considering subtyping SAD based on core fears. SAD was found to be a valid diagnosis in children and adolescents. Selective mutism could be considered in part as a young child's avoidance response to social fears. Pervasive test anxiety may belong not only to SAD, but also to generalized anxiety disorder. The data are equivocal regarding whether to consider avoidant personality disorder simply a severe form of SAD. Secondary data analyses, field trials, and validity tests are needed to investigate the recommendations and options.

Follow-up psychotherapy outcome of patients with dependent, avoidant and obsessive-compulsive personality disorders: A meta-analytic review

Assessing the number of patients who maintain their gains after the completion of therapy has been of interest to psychotherapy outcome researchers. The current study examines evidence related to the maintenance of treatment gains in individuals diagnosed with Cluster C personality disorders. Fifteen studies, published between 1982 and 2006, met the criteria for inclusion. The effect size standardized mean difference statistic was applied. In the majority of cases, most of the improvement occurred between pretreatment and posttreatment. However, social skills training often produced effect sizes that were larger for posttreatment follow-up. The study indicates that therapy gains are usually maintained at follow-up for Cluster C clients treated with cognitive-behavioral and psychodynamic approaches as well as social skills training. Uncertainty remains whether DPD, AVPD or OCPD patients benefited most from therapy.

Social support interventions: do they work?

Presence of support has repeatedly been linked to good long-term health outcomes based on demonstrations of better immune function, lower blood pressures, and reduced mortality (among others). Despite a massive literature on the benefits of support, there is surprisingly little hard evidence about how, and how well, social support interventions work. Using a computerized search strategy, 100 studies that evaluated the efficacy of such interventions were located. The presenting problems ranged from cancer, loneliness, weight loss, and substance abuse to lack in parenting skills, surgery, and birth preparation. For the purpose of review and evaluation, studies were subdivided into (1) group vs. individual interventions, (2) professionally led vs. peer-provided treatment, and (3) interventions where an increase of network size or perceived support was the primary target vs. those where building social skills (to facilitate support creation) was the focus. On the whole, this review provided some support for the overall usefulness of social support interventions. However, because of the large variety of existing different treatment protocols and areas of application, there is still not enough evidence to conclude which interventions work best for what problems. Specific methodological and conceptual difficulties that plague this area of research and directions for future research are discussed.

The efficacy of various modalities of psychotherapy for personality disorders: a systematic review of the evidence and clinical recommendations

The aim of this paper is to review the level of empirical evidence for four different formats and settings that are available for psychotherapy delivery, i.e., group psychotherapy, out-patient individual psychotherapy, day hospital psychotherapy, and in-patient psychotherapy. The focus is on studies which include a wide range of DSM-IV-TR Axis II personality disorders. The results show that various psychotherapeutic treatments have proven to be efficacious with respect to reducing symptomatology and personality pathology, and improving social functioning in patients with Cluster A, B, C, or not-otherwise-specified personality disorders. This is especially true for cognitive-behaviorally or psychodynamically oriented out-patient individual psychotherapies. However, some evidence indicates that this also applies to (1) long-term, psychodynamically oriented group psychotherapy, (2) short-term, psychodynamically oriented psychotherapy in a day hospital setting, and (3) various duration variants of psychodynamically oriented, in-patient psychotherapy programmes. The available evidence mostly applies to borderline, dependent, avoidant and not-otherwise-specified personality disorder, and perhaps also paranoid, obsessive-compulsive, and schizotypal personality disorder. It is unknown whether these conclusions also apply to schizoid, antisocial, narcissistic, and histrionic personality disorder.

Comparison of brief dynamic and cognitive-behavioural therapies in avoidant personality disorder

BACKGROUND

There is a paucity of controlled trials examining the effectiveness of individual psychotherapy in personality disorders, especially in patients with cluster C disorders.

AIMS

To compare the effectiveness of brief dynamic therapy and cognitive-behavioural therapy as out-patient treatment for people with avoidant personality disorder.

METHOD

Patients who met the criteria for avoidant personality disorder (n=62) were randomly assigned to 20 weekly sessions of either brief dynamic therapy (n = 23) or cognitive-behavioural therapy (n=21), or they were assigned to the waiting-list control group (n = 18). After the waiting period, patients in the control group were randomly assigned to one of the two therapies.

RESULTS

Patients who received cognitive-behavioural therapy showed significantly more improvements on a number of measures in comparison with those who had brief dynamic psychotherapy or were in the waiting-list control group. Results were maintained at follow-up.

CONCLUSIONS

Cognitive-behavioural therapy is more effective than waiting-list control and brief dynamic therapy. Brief dynamic therapy was no better than the waiting-list control condition.

Integrated wilderness therapy for avoidant personality disorder

Patients with avoidant personality disorder (APD) are difficult to treat because of their extensive social, emotional and cognitive avoidance. Few studies have addressed outcome in APD and there is no therapy of choice. In this quasi-experimental study, we integrated wilderness therapy in an inpatient group program (integrated wilderness therapy, IWT), in order to enhance outcome for patients with APD. We compared outcome of the IWT group with a similar inpatient group program without wilderness therapy: the comparison condition (CC). The subjects in the IWT-group (n=16) with DSM-IV APD were treated in 11.5 weeks. The subjects in the comparison group (n=37) were selected from our database with the same diagnostic criteria. The participants were examined at pre-care, admission, discharge and 1-year follow-up. Both groups were significantly improved, but there were no significant differences between them. There were some non-significant trends for males to gain most benefit from IWT, whereas females were more improved by the CC. The results indicate that by integrating wilderness therapy we were able to treat more impaired patients at shorter time with almost the same outcome.

Avoidant personality disorder: current status and future directions

Avoidant Personality Disorder (APD) is the topic of a growing body of research literature. In this article, we review empirical studies of APD with the goals of identifying the themes that underlie this work and pointing to new directions for future research. In particular, we recommend that future studies evaluate several unique factors postulated by personality theorists to be central to this condition.

Skills training as an adjunctive treatment for personality disorders

Personality disorders are usually treated with either psychodynamic or supportive psychotherapy, with psychotropic medication often used as an adjunctive treatment. However, patients with personality disorders pose special treatment issues, because their problems are pervasive and long-standing and they have entrenched deficits in many areas of functioning. In this article, the authors consider the role of skills training in the treatment of personality disorders. They describe a two-pronged approach to the treatment of personality disorders based on a model of deficit compensation. Because skills training has only been investigated in a very limited way in personality disorders, the authors first review research on the use of skills training in Axis I disorders as background for a discussion of ways in which skills training may be applicable to the treatment of Axis II disorders. They describe a number of skills training approaches (social skills training, anger management, and conversational skills) that can be used for a variety of different Axis I disorders. Skills training approaches that are targeted to specific types of disorders (substance use disorders, schizophrenia, anxiety disorders, adolescent problems) are also described. The authors then review what is known about the use of skills training in borderline personality disorder and avoidant personality disorder, and propose skills training approaches that may be useful for patients with paranoid personality disorder and antisocial personality disorder. Case examples are provided to demonstrate how skills training for personality disorders can be applied in clinical practice.

Treatment outcome of personality disorders

OBJECTIVE

To review the treatment outcome of personality disorders.

METHOD

A literature search of studies pertaining to personality disorder and outcome was conducted, and studies that focused primarily on Axis II were retained. Of these, naturalistic outcome studies were distinguished from those that addressed treatment outcome specifically. The treatment outcome studies were examined in terms of type of treatment intervention, dependent variables, and outcome.

RESULTS

Contrary to contemporary assumptions about Axis II, a substantial number of treatment outcome studies were identified. Trends in the assumptions underlying psychosocial and pharmacologic approaches were identified on the basis of dependent variables.

CONCLUSION

There is evidence that effective treatments exist to alleviate symptoms and reduce symptomatic behaviours that accompany personality disorders. What these results hold for the idea of remission from personality disorder is considered.