Avoidant Personality Disorder, Case vignette (1)

A CASE OF Avoidant Personality Disorder

By: THEODORE MILLON et al.

Notes:

(1) Numbers mark aspects of the case most consistent with DSM criteria as follow, and do not necessarily indicate that the case “meets” diagnostic criteria in this respect.

(2) Patient's name has been changed in respect to confidentiality, and name mentioned is not of a real existent person.

Case of Allison

Allison is a 22-year-old undergraduate at a local community college. She is clearly shy and uncomfortable in the clinical interview, but nevertheless complains of panic attacks so immobilizing that her contact with the outside world is limited to a bare minimum. With a new semester starting, she does not know if she will be able to attend classes. The pattern is always the same. Suddenly she notices her heart quicken, then she begins to sweat as the fear of an attack grows, then her heart begins to race faster and faster and she is overtaken by panic (1).

There is little joy in Allison’s life. She tries to work each day, takes care of necessary errands, and shops for food every few weeks. Generally, she lets things accumulate and then tries to do them all at once, to get it over with. In the past, she occasionally enjoyed volunteer work at a botanical garden, but has never held a real job (1).

When asked about her social life, she has difficulty naming friends. “My fear,” she states, “is that others won’t like me if they really find out about the real me!” Although her words are deeply felt, she never makes eye contact with the interviewer (2). She concedes that although others may be capable of succeeding in the world, she desperately wants to be left alone. Even when she is just sitting in class, she has difficulty believing that others who are laughing are not making fun of her (4).

Allison’s history goes far toward making sense of her symptoms. She has been reminded many times that her birth was an accident, something unpleasant that her mother and father “had to go through.” She cannot recall a time when she felt loved by her parents. “Not that they were neglectful,” she quickly points out, “but I always felt like a burden to them.” 

Life at home was without warmth or joy, with much time spent fantasizing alone in her room, something she still does today. Worse, her parents, themselves highly successful, had high expectations for her but were often excessively
critical, even of the smallest mistakes. Because of her shyness, she had to endure hours of merciless teasing from the other children, apparently the origin of a crippling self-consciousness that has followed her ever since. Unable to defend herself, she withdrew socially, as if to become smaller and less noticeable to others (6).

When asked about relationships, Allison refers to her only boyfriend, when she was a high school senior. “Even then,” she reflects, “I was afraid to be myself or voice any kind of opinion of my own (3). I was afraid he would dump me.” When asked about marriage, Allison admits she has dreams of being accepted unconditionally, but doubts that it will ever happen (2). Instead, she prefers to be alone, “where it’s safe, where no one can see your faults, much less judge you or criticize you for them.” “If you keep with what you know,” she says, “you at least don’t have to worry about embarrassing yourself.”(7)

DSM-IV Criteria

A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
(1) avoids occupational activities that involve significant interpersonal contact, because of fears of
criticism, disapproval, or rejection
(2) is unwilling to get involved with people unless certain of being liked
(3) shows restraint within intimate relationships because of the fear of being shamed or ridiculed
(4) is preoccupied with being criticized or rejected in social situations
(5) is inhibited in new interpersonal situations because of feelings of inadequacy
(6) views self as socially inept, personally unappealing, or inferior to others
(7) is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing

References

(1) Personality Disorders in Modern Life, second edition, 2000, 2004 by John Wiley & Sons, Inc.

(2)Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright 1994 American Psychiatric Association.

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