Case Study: Avoidant Personality Disorder (AVPD)
To better understand how AVPD manifests and develops in patients, Guina (2016) presents a case study. In it, a single female in her 30s presented with the chief complaint of anxiety around and difficulty adjusting to her new occupation. In therapy, however, the conversation shifted to her childhood in understanding her current state, illustrating the impacts of attachment on the development of AVPD.
The patient was raised by a single mother and never met her father, who had left their family. The mother treated her "as an afterthought" and described her father as someone who would "do anything for anybody," leading the patient to internalize a feeling of unwantedness–that the father "would do anything for anybody but her." The patient's mother also physically and emotionally abused her, beating her when she made mistakes on homework and extracurricular activities. As such, the patient ended up quitting activities to avoid making mistakes, paralleling how she would avoid social activities and occupational risks in adulthood. The mother was additionally a hoarder of personal belongings, and they lived without functional plumbing in unsanitary conditions. The patient thus felt "dirty" much of the time and suffered bullying due to her lack of personal hygiene. However, around teachers and peers, the patient lied that no problems existed at home, internalizing a fear of maternal retaliation as well as the idea that the situation was deserved.
When the patient was accepted to a major university to study writing, she became hopeful and excited to escape her mother. However, a car accident dashed those plans, and she spent weeks in the hospital with her mother preventing her from using pain medication. The patient ended up blaming her own hopefulness about her future for the collision. Thus followed a self-described "decade of coasting" in the patient's 20s, where she attended community college on and off and rarely went to class or did work. When she failed out and moved in with a partner, she felt "not happy or sad, just on autopilot." In the last few years, the patient went back to school and got a degree, but became avoidant of household chores when not avoidant of schoolwork. She had an abusive roommate, but never fought back because she "felt like [she] deserved it."
Eventually, the patient found a job in her field after three years of searching. She described it as not because of a lack of opportunities; rather, she feared making the wrong decision, social and occupational risks, and misplaced hope. She came to therapy after she found herself crying at her job without any triggers, procrastinating, and struggling to answer invitations to social events from co-workers.
This patient meets several DSM criteria for AVPD, including social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation, impairment of identity and self-direction, and reluctance to get involved with people. Applying psychodynamic theory to examine the impacts of the patient's childhood on her development, the patient's family history of maternal anxiety, hoarding, and abusive relationships held significant influence on her experience with AVPD later in life.
Primarily, the patient exhibited avoidant behaviors as a form of maladaptive defense mechanism in adulthood. Avoidant behavior was once adaptive to survive childhood–such as avoiding activities that would bring about mistakes and subsequent maternal berating–but in adulthood caused exhausted mental energy and life dysfunction. Although passivity helped the patient to feel more secure and safe, it prevented her from meeting her social and emotional needs and truly finding security. Her internalization that neglectful or abusive relationships were "deserved" from her childhood led her to have limited intimacy and remain within unhappy relationships.
In summary, the AVPD patient's early paternal abandonment and maternal neglect led to an insecure avoidant attachment style. Deprived of her basic emotional needs, she rarely sought comfort when distressed or expressed her emotions, learning to shy away from risks because those resulted in punishment and abuse during her childhood. This insecure attachment led her to be socially withdrawn, passive, and avoidant in adulthood.
Contributed by: Anna Kiesewetter
Reference
Guina, J. (2016). The Talking Cure of Avoidant Personality Disorder: Remission through Earned-Secure Attachment. American Journal of Psychotherapy, 70(3), 233-250. doi: 10.1176/appi.psychotherapy.2016.70.3.233.