avoidant personality disorder case study pdf

Academia.edu no longer supports Internet Explorer.

To browse Academia.edu and the wider internet faster and more securely, please take a few seconds to  upgrade your browser .

Enter the email address you signed up with and we'll email you a reset link.

• We're Hiring!
• Help Center

Psychoanalysis of Avoidant Personality Disorder: a Systematic Case Study of Process and Outcome

2009, Journal of the American Psychoanalytic Association

Related Papers

Psychotherapy: Theory, Research, Practice, Training

V. Dauphin , John Porcerelli

Journal of Clinical Psychology

Kristine Dahl Sørensen

Frontiers in Psychology

Stefan G Hofmann

Individuals with social phobia (social anxiety disorder) and avoidant personality typically hold a distorted and negative view of themselves as a social object. The case of Paul, an extreme case of social phobia with avoidant personality disorder, illustrates the complex interrelatedness between the perception of social norms, interpersonal relationships, and the self. Considering these variables in treatment can translate into powerful intervention strategies. Paul's therapy combined basic behavioral principles and novel cognitive intervention strategies to specifically modify his distorted sense of self as a social object. This intervention led to a dramatic improvement, which was maintained at a 1-year follow-up assessment.

Psychotherapy

Jamie Bedics

In Session: Psychotherapy in Practice

Cory Newman

Bar Ilan University

Most psychotherapy research has focused on treatment efficacy, using the common "gold standard" of randomized controlled trials (RCT) to examine pre-to-post treatment changes. Despite the great advantages of this methodology, it has shortcomings in describing change mechanisms within psychotherapy. The current dissertation joins a growing number of studies focused on change processes that occur within therapy. It is the first to study in-session change processes among clients diagnosed with avoidant personality disorder (APD), and also the first to do so within the context of schema therapy (ST) treatment. Sixty sessions were randomly selected from the treatments of 15 APD clients, each treated by a different schema therapist. These sessions were divided into 5-minute segments (n=645), which were coded by independent raters on two rating scales. These scales – one assessing therapist interventions and the other assessing client modes achieved adequate-to-high inter-rater reliability. The rating scale data were then used in three studies, each implementing a statistical method which is relatively novel within psychotherapy research. Study 1 made use of within-session mean-square-successive-difference (MSSD) scores to assess mode (self-state) fluctuations among APD clients. It found APD clients to be characterized by relative instability. The frequency, intensity, and rate of fluctuation of each mode are described in detail and their implications for therapy are elaborated. Study 2 made use of multilevel-regression models to reveal associations among therapist interventions and client mode changes within sessions. It found that a good implementation of the therapist stance was followed by a decrease in the avoidant/detached mode and by an increase in the healthy adult mode; a good implementation of emotion-focused and relational interventions was followed by a decrease in the over-compensating mode; a good implementation of cognitive interventions was followed by an increase in the vulnerable child and the dysfunctional parent modes; and a good implementation of behavioral interventions was followed by a decrease in the dysfunctional parent modes. These findings' implications for the therapy process are described in detail. ii Study 3 made use of time-series-panel-analyses (TSPA) to reveal three idiographic models of change among specific APD clients. These three distinct mode change models were chosen to demonstrate variants of APD clients that fell into (a) rigid, (b) confused, and (c) the receptive patterns. Each of these idiographic mode change models is described in detail and conclusions for specific tailored therapeutic focus are drawn. This dissertation is novel in several respects. Its focus on a micro-analytic inquiry of segment-by-segment therapy processes stands to contribute to ST research and practice in particular, and to research and practice with APD more broadly. It demonstrates the added value of the statistical methods used to psychotherapy research. And it illustrates the trans-diagnostic and trans-theoretical possibilities embedded in the mode concept to capture and measure the dynamic facets of personality, and to help guide both generic and individualized treatment strategies.

Felix Inchausti

Avoidant Personality Disorder (APD) is the most prevalent diagnosis amongst the personality disorders. However, it remains under-researched, and few psychotherapeutic approaches have proven effectiveness in treating the disorder. Focusing on specific elements of psychopathology may therefore help in refining treatments for this disorder. Here we present a case where Metacognitive Interpersonal Therapy (MIT) was used to directly address the negative metacognitive schemas held by clients with APD. We also describe the theoretical background of MIT and why it may be effective in the psychotherapeutic treatment of APD.

Psychology and Psychotherapy: Theory, Research and Practice

Rosemary Cogan

RELATED PAPERS

miranda salvador

100 Days of Real Food Meal Planner

Sara D. Worrell

Iskolakultúra

Hypertension

Michael Michalkiewicz

International Journal of …

Stefan David

Estudos Econômicos (São Paulo)

Mauricio Bugarin

Journal of the Egyptian Society of Parasitology

Revista Controvérsia

Marco Aurelio Peri Guedes

Emerging Infectious Diseases

Hervé Pascalis

Nur Almaidah

Ulfi Marendy

Stefano Boni

IEEE Transactions on Visualization and Computer Graphics

Claudio Silva

Annales de Dermatologie et de Vénéréologie

A. Djeridane

Journal of Social Sciences and Management Studies

Saleh M U S S A ALAWI

Acta Paediatrica

INTERNATIONAL CONFERENCE ON SCIENCE AND APPLIED SCIENCE (ICSAS) 2021

Juliana Purba 1810246944

Jacques Cormier

L'Encéphale

David Mateus Fonseca

Journal of Contextual Behavioral Science

Rebecca Grudin

Primate Biology

José Lisbinio Cruz Guimaraes

Nanotechnology

Ilkka Tittonen

Biochemical Pharmacology

Cees Van Den Berg

Pharmaceutical patent analyst

absar talat

See More Documents Like This

RELATED TOPICS

•   We're Hiring!
•   Help Center
• Find new research papers in:
• Health Sciences
• Earth Sciences
• Cognitive Science
• Mathematics
• Computer Science
• Academia ©2024

Avoidant Personality Disorder: a Current Review

• Personality Disorders (C Schmahl, Section Editor)
• Published: 01 February 2016
• Volume 18 , article number  29 , ( 2016 )

Cite this article

• Anna Weinbrecht 1 ,
• Lars Schulze 1 ,
• Johanna Boettcher 1 &
• Babette Renneberg 1  

17k Accesses

53 Citations

11 Altmetric

Explore all metrics

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price includes VAT (Russian Federation)

Instant access to the full article PDF.

Rent this article via DeepDyve

Institutional subscriptions

Similar content being viewed by others

Understanding social anxiety disorder in adolescents and improving treatment outcomes: applying the cognitive model of clark and wells (1995).

Eleanor Leigh & David M. Clark

Social Anxiety Disorder

Anxiety Disorders in the DSM-5: Changes, Controversies, and Future Directions

Papers of particular interest, published recently, have been highlighted as: • of importance •• of major importance.

Cramer V, Torgersen S, Kringlen E. Personality disorders and quality of life. A population study. Compr Psychiatry. 2006;47(3):178–84.

Article   PubMed   Google Scholar  

Ullrich S, Farrington DP, Coid JW. Dimensions of DSM-IV personality disorders and life-success. J Pers Disord. 2007;21(6):657–63.

Olsson I, Dahl AA. Avoidant personality problems—their association with somatic and mental health, lifestyle, and social network. A community-based study. Compr Psychiatry. 2012;53(6):813–21.

Crawford TN, Cohen P, Johnson JG, Kasen S, First MB, Gordon K, et al. Self-reported personality disorder in the children in the community sample: convergent and prospective validity in late adolescence and adulthood. J Pers Disord. 2005;19(1):30–52.

Grant BF, Hasin DS, Stinson FS, Dawson DA, Chou SP, Ruan WJ, et al. Prevalence, correlates, and disability of personality disorders in the United States: results from the national epidemiologic survey on alcohol and related conditions. J Clin Psychiatry. 2004;65(7):948–58.

Torgersen S. The nature (and nurture) of personality disorders. Scand J Psychol. 2009;50(6):624–32.

Zimmerman M, Rothschild L, Chelminski I. The prevalence of DSM-IV personality disorders in psychiatric outpatients. Am J Psychiatry. 2005;162(10):1911–8.

American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: Author; 2013.

Google Scholar  

Cox BJ, Pagura J, Stein MB, Sareen J. The relationship between generalized social phobia and avoidant personality disorder in a national mental health survey. Depress Anxiety. 2009;26(4):354–62.

Hofmann SG, Newman MG, Ehlers A, Roth WT. Psychophysiological differences between subgroups of social phobia. J Abnorm Psychol. 1995;104(1):224–31.

Article   CAS   PubMed   Google Scholar  

Herbert JD, Hope DA, Bellack AS. Validity of the distinction between generalized social phobia and avoidant personality disorder. J Abnorm Psychol. 1992;101(2):332–9.

Friborg O, Martinussen M, Kaiser S, Overgard KT, Rosenvinge JH. Comorbidity of personality disorders in anxiety disorders: a meta-analysis of 30 years of research. J Affect Disord. 2013;145(2):143–55.

Alden LE, Laposa JM, Taylor CT, Ryder AG. Avoidant personality disorder: current status and future directions. J Pers Disord. 2002;16(1):1–29.

Bogels SM, Alden L, Beidel DC, Clark LA, Pine DS, Stein MB, et al. Social anxiety disorder: questions and answers for the DSM-V. Depress Anxiety. 2010;27(2):168–89.

Reich J. Chapter 2—avoidant personality disorder and its relationship to social anxiety disorder. In: Hofmann SG, DiBartolo PM, editors. Social anxiety. 3rd ed. San Diego: Academic; 2014. p. 27–44.

Marques L, Porter E, Keshaviah A, Pollack MH, Van Ameringen M, Stein MB, et al. Avoidant personality disorder in individuals with generalized social anxiety disorder: what does it add? J Anxiety Disord. 2012;26(6):665–72.

Article   PubMed Central   PubMed   Google Scholar  

Eikenaes I, Hummelen B, Abrahamsen G, Andrea H, Wilberg T. Personality functioning in patients with avoidant personality disorder and social phobia. J Pers Disord. 2013;27(6):746–63.

Rettew DC. Avoidant personality disorder, generalized social phobia, and shyness: putting the personality back into personality disorders. Harv Rev Psychiatry. 2000;8(6):283–97.

Sanislow CA, Bartolini EE, Zoloth EC. Avoidant personality disorder. In: Ramachandran VS, editor. Encyclopedia of human behavior. 2nd ed. San Diego: Academic; 2012. p. 257–66.

Chapter   Google Scholar  

Skodol AE, Bender DS, Morey LC, Clark LA, Oldham JM, Alarcon RD, et al. Personality disorder types proposed for DSM-5. J Pers Disord. 2011;25(2):136–69.

Stuart S, Pfohl B, Battaglia M, Bellodi L, Grove W, Cadoret R. The cooccurrence of DSM-III-R personality disorders. J Pers Disord. 1998;12(4):302–15.

Bachrach N, Croon MA, Bekker MH. Factor structure of self-reported clinical disorders and personality disorders: a review of the existing literature and a factor analytical study. J Clin Psychol. 2012;68(6):645–60.

Caspi A, Houts RM, Belsky DW, Goldman-Mellor SJ, Harrington H, Israel S, et al. The p factor: one general psychopathology factor in the structure of psychiatric disorders? Clin Psychol Sci. 2014;2(2):119–37.

Wright AG, Pincus AL, Lenzenweger MF. A parallel process growth model of avoidant personality disorder symptoms and personality traits. Personal Disord. 2013;4(3):230–8. In this longitudinal study, the rates of change in avoidant personality disorder symptoms were associated to rates of change in normal personality traits (interpersonal dominance, affiliation, and neuroticism). This supports the proposition that personality disorders can be conceptualized as expressions of normal personality traits and stresses the crucial role of neuroticism for avoidant personality disorder.

Lenzenweger MF. Stability and change in personality disorder features: the Longitudinal Study of Personality Disorders. Arch Gen Psychiatry. 1999;56(11):1009–15.

Grilo CM, Sanislow CA, Gunderson JG, Pagano ME, Yen S, Zanarini MC, et al. Two-year stability and change of schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders. J Consult Clin Psychol. 2004;72(5):767–75.

Johnson JG, Cohen P, Kasen S, Skodol AE, Hamagami F, Brook JS. Age-related change in personality disorder trait levels between early adolescence and adulthood: a community-based longitudinal investigation. Acta Psychiatr Scand. 2000;102(4):265–75.

Sanislow CA, Little TD, Ansell EB, Grilo CM, Daversa M, Markowitz JC, et al. Ten-year stability and latent structure of the DSM-IV schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders. J Abnorm Psychol. 2009;118(3):507–19.

Hallquist MN, Lenzenweger MF. Identifying latent trajectories of personality disorder symptom change: growth mixture modeling in the longitudinal study of personality disorders. J Abnorm Psychol. 2013;122(1):138–55. In this longitudinal study, latent trajectories of personality dysfunction were investigated. Results indicated that avoidant personality disorder can develop at a later stage of life and that this is associated with lower positive emotionality.

Gjerde LC, Czajkowski N, Roysamb E, Ystrom E, Tambs K, Aggen SH et al. A longitudinal, population-based twin study of avoidant and obsessive-compulsive personality disorder traits from early to middle adulthood. Psychol Med. 2015:1–10. This longitudinal twin study provided support that genetic factors contribute more to the phenotypic stability of avoidant personality disorder than environmental factors.

Hopwood CJ, Morey LC, Donnellan MB, Samuel DB, Grilo CM, McGlashan TH, et al. Ten-year rank-order stability of personality traits and disorders in a clinical sample. J Pers. 2013;81(3):335–44. This study assessed 10-year stability of personality traits and personality disorder dimensions in a clinical sample. Stability was relatively greater for traits than personality disorders.

Gjerde LC, Czajkowski N, Roysamb E, Orstavik RE, Knudsen GP, Ostby K, et al. The heritability of avoidant and dependent personality disorder assessed by personal interview and questionnaire. Acta Psychiatr Scand. 2012;126(6):448–57.

Article   PubMed Central   CAS   PubMed   Google Scholar  

Isomura K, Boman M, Ruck C, Serlachius E, Larsson H, Lichtenstein P, et al. Population-based, multi-generational family clustering study of social anxiety disorder and avoidant personality disorder. Psychol Med. 2015;45(8):1581–9.

Joyce PR, McKenzie JM, Luty SE, Mulder RT, Carter JD, Sullivan PF, et al. Temperament, childhood environment and psychopathology as risk factors for avoidant and borderline personality disorders. Aust N Z J Psychiatry. 2003;37(6):756–64.

PubMed   Google Scholar  

Meyer B, Carver CS. Negative childhood accounts, sensitivity, and pessimism: a study of avoidant personality disorder features in college students. J Pers Disord. 2000;14(3):233–48.

Eikenaes I, Egeland J, Hummelen B, Wilberg T. Avoidant personality disorder versus social phobia: the significance of childhood neglect. PLoS One. 2015;10(3), e0122846.

Carr SN, Francis AJ. Early maladaptive schemas and personality disorder symptoms: an examination in a non-clinical sample. Psychol Psychother. 2010;83(4):333–49.

Renneberg B, Goldstein AJ, Phillips D, Chambless DL. Intensive behavioral group treatment of avoidant personality-disorder. Behav Ther. 1990;21(3):363–77.

Article   Google Scholar  

Alden L. Short-term structured treatment for avoidant personality-disorder. J Consult Clin Psychol. 1989;57(6):756–64.

Stravynski A, Belisle M, Marcouiller M, Lavallee YJ, Elie R. The treatment of avoidant personality disorder by social skills training in the clinic or in real-life settings. Can J Psychiatry. 1994;39(8):377–83.

CAS   PubMed   Google Scholar  

Beck AT, Freeman AM. Cognitive therapy of personality disorders. New York, NY, US: Guilford Press; 1990.

Clark DM, Wells A. A cognitive model of social phobia. In: Heimberg RG, Liebowitz MR, Hope DA, Schneier FR, editors. Social phobia: diagnosis, assessment and treatment. New York: Guildford Press; 1995. p. 66–93.

Emmelkamp PM, Benner A, Kuipers A, Feiertag GA, Koster HC, van Apeldoorn FJ. Comparison of brief dynamic and cognitive-behavioural therapies in avoidant personality disorder. Br J Psychiatry. 2006;189:60–4.

Rees CS, Pritchard R. Brief cognitive therapy for avoidant personality disorder. Psychotherapy (Chic). 2015;52(1):45–55.

Strauss JL, Hayes AM, Johnson SL, Newman CF, Brown GK, Barber JP, et al. Early alliance, alliance ruptures, and symptom change in a nonrandomized trial of cognitive therapy for avoidant and obsessive-compulsive personality disorders. J Consult Clin Psychol. 2006;74(2):337–45.

Borge FM, Hoffart A, Sexton H, Clark DM, Markowitz JC, McManus F. Residential cognitive therapy versus residential interpersonal therapy for social phobia: a randomized clinical trial. J Anxiety Disord. 2008;22(6):991–1010.

Abbass A, Sheldon A, Gyra J, Kalpin A. Intensive short-term dynamic psychotherapy for DSM-IV personality disorders: a randomized controlled trial. J Nerv Ment Dis. 2008;196(3):211–6.

Barber JP, Morse JQ, Krakauer ID, Chittams J, Crits-Christoph K. Change in obsessive-compulsive and avoidant personality disorders following time-limited supportive-expressive therapy. Psychotherapy (Chic). 1997;34(2):133–43.

Svartberg M, Stiles TC, Seltzer MH. Randomized, controlled trial of the effectiveness of short-term dynamic psychotherapy and cognitive therapy for cluster C personality disorders. Am J Psychiatry. 2004;161(5):810–7.

Leichsenring F, Salzer S. A unified protocol for the transdiagnostic psychodynamic treatment of anxiety disorders: an evidence-based approach. Psychotherapy (Chic). 2014;51(2):224–45.

Luborsky L, Mark D. Short-term supportive-expressive psychoanalytic psychotherapy. In: Crits-Christoph P, Barber JP, Crits-Christoph P, Barber JP, editors. Handbook of short-term dynamic psychotherapy. New York, NY, US: Basic Books; 1991. p. 110–36.

Young JE, Klosko JS, Weishaar ME. Schema therapy: a practitioner’s guide. New York, NY, US: Guilford Press; 2003.

Arntz A. Schematherapie für Cluster-C-Persönlichkeitsstörungen. Z Psychiatr Psychol Psychother. 2011;59(3):195–204.

Weertman A, Arntz A. Effectiveness of treatment of childhood memories in cognitive therapy for personality disorders: a controlled study contrasting methods focusing on the present and methods focusing on childhood memories. Behav Res Ther. 2007;45(9):2133–43.

Bamelis LL, Evers SM, Spinhoven P, Arntz A. Results of a multicenter randomized controlled trial of the clinical effectiveness of schema therapy for personality disorders. Am J Psychiatry. 2014;171(3):305–22. This study demonstrated that a greater proportion of patients with Cluster C personality disorder treated with schema therapy recovered in comparison to clarification-oriented psychotherapy and treatment as usual.

Skewes SA, Samson RA, Simpson SG, van Vreeswijk M. Short-term group schema therapy for mixed personality disorders: a pilot study. Front Psychol. 2014;5:1592.

PubMed Central   PubMed   Google Scholar  

Group schema therapy versus group cognitive behavioral therapy for social anxiety disorder with comorbid avoidant personality disorder [database on the Internet]. in Trialregister.nl [Internet]. NTR number: NTR3921. 2013. Available from: Available online at: http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3921 . Accessed:

Dimaggio G, D’Urzo M, Pasinetti M, Salvatore G, Lysaker PH, Catania D, et al. Metacognitive interpersonal therapy for co-occurrent avoidant personality disorder and substance abuse. J Clin Psychol. 2015;71(2):157–66.

Pos AE. Emotion focused therapy for avoidant personality disorder: pragmatic considerations for working with experientially avoidant clients. J Contemp Psychother. 2014;44(2):127–39.

Chan CC, Bach PA, Bedwell JS. An integrative approach using third-generation cognitive-behavioral therapies for avoidant personality disorder. Clinical Case Studies. 2015;1–16.

Gilbert SE, Gordon KC. Interpersonal psychotherapy informed treatment for avoidant personality disorder with subsequent depression. Clinical Case Studies. 2012;12(2):111–2.

Brown EJ, Heimberg RG, Juster HR. Social phobia subtype and avoidant personality-disorder—effect on severity of social phobia, impairment, and outcome of cognitive-behavioral treatment. Behav Ther. 1995;26(3):467–86.

Feske U, Perry KJ, Chambless DL, Renneberg B, Goldstein AJ. Avoidant personality disorder as a predictor for treatment outcome among generalized social phobics. J Pers Disord. 1996;10(2):174–84.

Hope DA, Herbert JD, White C. Diagnostic subtype, avoidant personality-disorder, and efficacy of cognitive-behavioral group-therapy for social phobia. Cognit Ther Res. 1995;19(4):399–417.

Huppert JD, Strunk DR, Ledley DR, Davidson JR, Foa EB. Generalized social anxiety disorder and avoidant personality disorder: structural analysis and treatment outcome. Depress Anxiety. 2008;25(5):441–8.

Oosterbaan DB, van Balkom AJ, Spinhoven P, de Meij TG, van Dyck R. The influence on treatment gain of comorbid avoidant personality disorder in patients with social phobia. J Nerv Ment Dis. 2002;190(1):41–3.

Liebowitz MR, Gorman JM, Fyer AJ, Klein DF. Social phobia. Review of a neglected anxiety disorder. Arch Gen Psychiatry. 1985;42(7):729–36.

Herbert JD, Gaudiano BA, Rheingold AA, Myers VH, Dalrymple K, Nolan EM. Social skills training augments the effectiveness of cognitive behavioral group therapy for social anxiety disorder. Behav Ther. 2005;36(2):125–38.

Renner F, van Goor M, Huibers M, Arntz A, Butz B, Bernstein D. Short-term group schema cognitive-behavioral therapy for young adults with personality disorders and personality disorder features: associations with changes in symptomatic distress, schemas, schema modes and coping styles. Behav Res Ther. 2013;51(8):487–92. This pilot study determined the effects of group schema therapy in patients with personality disorder. Global distress and underlying vulnerabilities in terms of maladaptive schemas decreased from pre- to post-treatment.

Ahmed U, Gibbon S, Jones Hannah F, Huband N, Ferriter M, Völlm Birgit A et al. Psychological interventions for avoidant personality disorder. Cochrane Database Syst Rev. 2014 doi: 10.1002/14651858.CD009549.pub2

Ahmed U, Gibbon S, Jones Hannah F, Huband N, Ferriter M, Völlm Birgit A et al. Pharmacological interventions for avoidant personality disorder. Cochrane Database Syst Rev. 2014 doi: 10.1002/14651858.CD009304.pub2

Download references

Author information

Authors and affiliations.

Clinical Psychology and Psychotherapy, Freie Universität Berlin, Habelschwerdter Allee 45, 14195, Berlin, Germany

Anna Weinbrecht, Lars Schulze, Johanna Boettcher & Babette Renneberg

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Anna Weinbrecht .

Ethics declarations

Conflict of interest.

The authors declare that they have no competing interests.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Personality Disorders

Rights and permissions

Reprints and permissions

About this article

Weinbrecht, A., Schulze, L., Boettcher, J. et al. Avoidant Personality Disorder: a Current Review. Curr Psychiatry Rep 18 , 29 (2016). https://doi.org/10.1007/s11920-016-0665-6

Download citation

Published : 01 February 2016

DOI : https://doi.org/10.1007/s11920-016-0665-6

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Avoidant personality disorder
• Psychotherapy

Advertisement

• Find a journal
• Publish with us
• Track your research

Module 12: Personality Disorders

Avoidant personality disorder, learning objectives.

• Describe the characteristics and diagnosis of avoidant personality disorder

Cluster C personality disorders include avoidant, dependent, and obsessive-compulsive personality disorders. Individuals with these disorders often appear anxious, fearful, or clingy (a mnemonic to help remember Cluster C disorders are the three C’s—cowardly, clingy, and compulsive). Avoidant personality disorders exhibit a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. Dependent personality disorders show a pattern of submissive and clinging behavior that evidence an excessive need to be taken care of. Lastly, obsessive-compulsive personality disorders manifest a preoccupation with orderliness, perfectionism, and control.

People with avoidant personality disorder (AvPD) often consider themselves to be socially inept or personally unappealing and avoid social interaction for fear of being ridiculed, humiliated, rejected, or disliked. They often avoid becoming involved with others unless they are certain they will be liked. As the name suggests, the main coping mechanism of those with avoidant personality disorder (AvPD) is avoidance of feared stimuli.

Those affected display a pattern of severe social anxiety, social inhibition, feelings of inadequacy and inferiority, extreme sensitivity to negative evaluation and rejection, and avoidance of social interaction despite a strong desire for intimacy.

According to the DSM-5 ,  avoidant personality disorder (AvPD) diagnosis refers to a widespread pattern of inhibition around people, feeling inadequate, and being very sensitive to negative evaluation. Symptoms begin by early adulthood and occur in a range of situations.

Figure 1. People with AvPD often have a negative perception of themselves.

Four of the following seven specific symptoms should be present:

• avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection
• is unwilling to get involved with people unless certain of being liked
• shows restraint within intimate relationships because of the fear of being shamed or ridiculed
• is preoccupied with being criticized or rejected in social situations
• is inhibited in new interpersonal situations because of feelings of inadequacy
• views self as socially inept, personally unappealing, or inferior to others
• is unusually reluctant to take personal risk or to engage in any new activities because they may prove embarrassing

Differential Diagnosis

In contrast to social anxiety disorder, a diagnosis of AvPD also requires that the general criteria for a personality disorder are met. According to DSM-5, AvPD must be differentiated from similar personality disorders such as dependent, paranoid, schizoid, and schizotypal. But these disorders can also occur together; this is particularly likely for AvPD and dependent personality disorder. Thus, if criteria for more than one personality disorder are met, all can be diagnosed.  There is also an overlap between avoidant and schizoid personality traits, and AvPD may have a relationship to the schizophrenia spectrum.

Comorbidity

AvPD is reported to be especially prevalent in people with anxiety disorders, although estimates of comorbidity vary widely due to differences in (among others) diagnostic instruments. Research suggests that approximately 10–50% of people who have panic disorder with agoraphobia have avoidant personality disorder, as well as about 20–40% of people who have social anxiety disorder. In addition, AvPD is more prevalent in people who have comorbid social anxiety disorder and generalized anxiety disorder than in those who have only one of the aforementioned conditions.  Some studies report prevalence rates of up to 45% among people with generalized anxiety disorder and up to 56% of those with obsessive-compulsive disorder. Post-traumatic stress disorder is also commonly comorbid with avoidant personality disorder.

Epidemiology

Data from the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions indicates a prevalence rate of 2.36% in the American general population. It appears to occur with equal frequency in males and females.

Figure 2. Childhood neglect is a risk factor for AvPD.

Causes of AvPD are not clearly defined, but appear to be influenced by a combination of social, genetic, and psychological factors. The disorder may be related to temperamental factors that are inherited.

Childhood emotional neglect (in particular, the rejection of a child by one or both parents) and peer group rejection are associated with an increased risk for its development; however, it is possible for AvPD to occur without any notable history of abuse or neglect.

Treatment of avoidant personality disorder can employ various techniques, such as social skills training, psychotherapy, cognitive therapy, exposure treatment to gradually increase social contacts, group therapy for practicing social skills, and sometimes drug therapy.

Key Takeaways: avoidant personality disorder

Case study: avoidant personality disorder.

The patient was 35-year-old, unmarried data technician William, referred to a specialized treatment program for personality disorders from an outpatient drug addiction service. His personality pathology was considered more devastating than his substance abuse. Presenting complaints included low self-esteem, loneliness, a sense of emptiness, suicidal ideation, social isolation, substance abuse, and general dissatisfaction with life. Present complaints had been chronic in nature, dating back to childhood.

William recalled having daily suicidal thoughts for several years in his early youth. His avoidant behavior was more prominent than his level of experienced anxiety. William’s most prominent feature was a pervasive fear of being ridiculed when interacting with others, and he was diagnosed with avoidant personality disorder.

In a group-based treatment program lasting for 20 weeks, he was a regular, but somewhat detached participant. The therapists encountered a series of problems related to passivity: he postponed most of his obligations, resisted sorting out practical affairs, did not pay his bills, and avoided contacting people who could be helpful.

Watch this video to learn more about behaviors associated with avoidant personality disorder.

You can view the transcript for “Avoidant Personality Disorder.. What is it?” here (opens in new window) .

avoidant personality disorder:  personality disorder characterized by patterns of social withdrawal, inadequacy, and fear of criticism

• Modification, adaptation, and original content. Authored by : Julie Manley for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• Textbook of Psychiatry. Provided by : Wikibooks. Located at : https://en.wikibooks.org/wiki/Textbook_of_Psychiatry/Print_version#Avoidant_Personality_Disorder . License : CC BY-SA: Attribution-ShareAlike
• Avoidant Personality Disorder.. What is it?. Provided by : Psych2go. Located at : https://www.youtube.com/watch?v=fFNA4De2mAc&feature=emb_logo . License : Other . License Terms : Standard YouTube License
• Sad. Authored by : Kevin Kosi. Located at : https://www.nappy.co/?s=sad . License : CC0: No Rights Reserved
• Sad girl. Authored by : Martin Vorel . Located at : https://libreshot.com/small-sad-girl-on-the-beach/ . License : Public Domain: No Known Copyright

The Avoidant Patient - A Case Study

Read therapy session notes from patient diagnosed with Avoidant Personality Disorder. See what it's like living with Avoidant Personality Disorder.

Notes of first therapy session with Gladys, female, 26, diagnosed with Avoidant Personality Disorder

"I would like to be normal" - says Gladys and blushes purple. In which sense is she abnormal? She prefers reading books and watching movies with her elderly mother to going out with her colleagues to the occasional office party. Maybe she doesn't feel close to them? How long has she been working with these people? Eight years in the same firm and "not one raise in salary" - she blurts out, evidently hurt. Her boss bullies her publicly and the searing shame of it all prevents her from socializing with peers, suppliers, and clients.

Does she have a boyfriend? I must be mocking her. Who would date an ugly duckling, plain secretary like her? I disagree wholeheartedly and in details with her self-assessment. I think that she is very intelligent. She half rises from her seat then thinks better of it: "Please, doctor, there no need to lie to me just in order to make me feel better. I know my good sides and they don't amount to much. If we disagree on this crucial point, perhaps I should start looking for another therapist."

A glass of water and mounds of tissue paper later, we are back on track. She dreads the idea of group therapy. "I am a social cripple. I can't work with other people. I declined a promotion to avoid working in a team." Her boss thought highly of her until she turned his offer down, so in effect it's all her fault and she has earned the abuse she is being subjected to on a daily basis. And, anyhow, he overestimated her capabilities and skills.

Why can't she interact with her co-workers? "Well, that's precisely what we are supposed to find out, isn't it?" - she retorts. Everyone is too critical and opinionated and she can't stand it. She accepts people as they are, unconditionally - why can't they treat her the same way? She fantasizes about getting married one day to a soulmate, someone who would love and cherish her regardless of her blemishes.

I ask her to describe how she thinks she is being perceived by others. "Shy, timid, lonely, isolated, invisible, quiet, reticent, unfriendly, tense, risk-averse, resistant to change, reluctant, restricted, hysterical, and inhibited." That's quite a list, I comment, now how does she view herself? The same, she largely agrees with people's perceptions of her "but it doesn't give them the right to ridicule or torment her just because she is different."

This article appears in my book, "Malignant Self Love - Narcissism Revisited"

next: The Histrionic Patient ~ back t o: Case Studies: Table of Contents

APA Reference Vaknin, S. (2009, October 1). The Avoidant Patient - A Case Study, HealthyPlace. Retrieved on 2024, April 10 from https://www.healthyplace.com/personality-disorders/malignant-self-love/avoidant-patient-a-case-study

Medically reviewed by Harry Croft, MD

Related Articles

Discussing narcissism, famous people with schizotypal personality disorder, i cannot forgive: piercing people's emotional shields, narcissists and psychopaths - responsibility and other matters, narcissistic humiliation and injury, narcissism by proxy, the diagnostic and statistical manual (dsm) - pros and cons.

2024 HealthyPlace Inc. All Rights Reserved. Site last updated April 10, 2024

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Medicina (Kaunas)

Borderline Personality Disorder “Discouraged Type”: A Case Report

Lavinia duică.

1 Faculty of Medicine, “Lucian Blaga” University of Sibiu, 550169 Sibiu, Romania; [email protected] (L.D.); [email protected] (M.T.); [email protected] (G.B.)

2 “Dr. Gheorghe Preda” Clinical Psychiatric Hospital, 550082 Sibiu, Romania

Elisabeta Antonescu

Maria totan, gabriela boța, sînziana călina silișteanu.

3 Faculty of Medicine and Biological Sciences, “Stefan cel Mare” University of Suceava, 720229 Suceava, Romania; [email protected]

Borderline Personality Disorder (BPD) is a mental illness associated with a significant degree of distress and impairment because of the difficulties in effectively regulating emotions. BPD is frequently associated with Depressive Disorders, most commonly Major Depressive Disorder and Dysthymia. Here, we present a case report of an 18-year-old female patient hospitalized with a severe depressive episode and psychotic symptoms. A few months after discharge, the interpersonal difficulties, unstable self-image, fear of chronic abandonment, feeling of emptiness, paranoid ideation, helplessness, obsessive-compulsive elements, perfectionism, and social retreat led to the patient’s impaired functionality. The spectrum of signs and symptoms presented were characteristic of BPD. The specific presentation of mixed dependent/avoidant pattern of personality, with persistent feelings of guilt and shame, social anxiety, emotional attachments, obsessions, and feelings of inadequacy have further narrowed the diagnosis to discouraged BPD, as described by Theodore Millon. In our case, this particular subtype of personality disorder can be understood as BPN associated with social perfectionism. Both BPD and perfectionism, as a trait personality, were thought to exacerbate issues with self-conception and identity formation in this patient.

1. Introduction

Borderline Personality Disorder (BPD) is associated with significant emotional suffering and functional impairment [ 1 ], including low occupational and educational attainment, difficulty in forming long-term relationships, increased partner conflict, sexual risk-taking, low levels of social support, low life satisfaction, and increased service use [ 2 ]. The most frequently co-occurring psychiatric disorders with BPD are Depressive Disorders (DD), most commonly Major Depressive Disorder (MDD) and Dysthymia. Between 70 and 90% of individuals with BPD go through at least one major depressive episode or exhibit another depressive disorder throughout the course of their lives [ 3 ]. According to Linehan’s biopsychosocial model, BPD has also been associated with childhood maltreatment and an invalidating family environment [ 4 ]. Indeed, childhood maltreatment, including family adversity, exposure to physical and sexual abuse, or neglect, has been found to be a robust and predictive risk factor for BPD [ 5 ].

The high prevalence of comorbid pathology amongst patients with BPD is widely recognized [ 6 ]. Therefore, a large variation in the expression of BPD pathology is apparent in clinical practice. For example, Critchfield et al. [ 7 ] describe three subtypes of BPD patients: those with co-occurring cluster A Personality Disorder (PD) traits (elevated schizotypal and paranoid features), those with cluster B traits of PD (elevated narcissistic and histrionic features), and those with cluster C traits of PD (elevated avoidant and obsessive-compulsive features). In Theodore Millon’s evolutionary model of personology, subtypes describe variations of each of the prototypical personality disorders derived from research and clinical observation [ 8 ]. Each subtype, or prototypical variant, shares the core features of the main prototype with one, two, or three other different PD. Millon’s four subtypes of Borderline Personality Disorder are: discouraged, self-disruptive, impulsive, and petulant.

In a recent study, the profile of the “inhibited” subtype resembled the “Discouraged” subtype characterized by avoidant, dependent features and unexpressed anger. These patients internalize more, are less impulsive, and are less likely to communicate their emotions [ 9 ]. The case brought to our attention was a patient who presented to the hospital with a recurrent, major depressive episode with psychotic symptoms, who, after the resolution of the acute symptomatology, was diagnosed with BPD, discouraged type. This is an interesting clinical case that resembles both features of cluster B Personality Disorder (dramatic, emotional, or erratic disorders) and perfectionism, a trait associated with cluster C Personality Disorder (anxious or fearful disorders) [ 1 ] as seen from the psychopathological features presented below. This combination posed significant challenges in accurately determining diagnosis and will aid clinicians in treatment recommendation.

2. Case Presentation

An 18-year-old female patient, from the rural region of Romania, was brought by her father to the emergency department for severe anxiety, suspiciousness, weight loss, food negativism, complex auditory and visual hallucinations, and fragmentary paranoid ideas. At age 16, the patient had a hospital admission to the pediatric psychiatric department with depressive and obsessive-compulsive symptoms and general low functionality in daily and school activities. She was diagnosed with a severe depressive episode and obsessive-compulsive disorder (OCD). At age 17, she was again diagnosed as an outpatient with OCD for obsessive-compulsive symptoms, low functionality, and school dropout. She was treated with Olanzapine 15 mg; however, after a few weeks, the treatment was discontinued at the request of her father because he considered that the treatment was “too strong”, and that his daughter did not need a psychiatric treatment, although there were no adverse reactions to the drug.

Life and family history showed that the patient lived in the rural area with her parents and two brothers with whom she had relatively harmonious relationships. She studied for three years at the High School for Arts, painting section, and, at some point, she developed a good reputation for her artistic talent. Her father told us that he considered that a major trauma in his daughter’s life was her deep disappointment at the inability of her family to afford the financial costs for studying anime in Japan, which was her exclusive life project during that period of time. When admitted to the hospital, the patient had no occupation and had dropped out of school for the past year.

Sometime after her first admission to the adult psychiatric ward, the patient communicated to us some information about her life history. She had tense interactions with her former and current classmates, who considered her “weird”, and “different from others”, because of her social inhibition and psychomotor slowness, and mockingly calling her “the little painter”. She felt sexually abused by her classmates (indecent gestures of sexual nature, use of trivial language), culminating in a psycho-traumatic event after she witnessed an erotic act of someone close to her. She felt that she did not have the protection and warmth from her family, and she did not feel sufficiently understood.

After being exposed to multiple psycho-traumatic events, which can be referred to as “emotional bullying” based on the patient’s statements, in a couple of years, the patient gradually became socially withdrawn and dropped out of school in the 11th grade. At the same time, she became addicted to watching anime, stating that “I was beginning to think I was a character”. The persistence of this situation over time led to psychiatric symptoms such as depression and obsessive-compulsive symptoms that have been associated with impaired functionality and dropping out of school. The patient described herself as shy, emotionally unstable, sensitive to criticism, and perfectionist, rigid, hesitant, undecided, and being critical of herself.

At admission, clinical examination revealed very low facial expressions and gestures, distracted gaze, severe anxiety, carelessness, weekly cooperating, reduced verbal contact in simple sentences (partial verbal negativity), low tone of voice, present consciousness, and temporally-spatially oriented. In terms of perception, the patient presented with complex visual and hallucinations (“I see small, black monsters with fiery eyes telling me what to do”), auditory hallucinations (“I hear voices criticizing me”). Examination of cognitive functions indicated spontaneous and voluntary hypoprosexia, fixation hypomnesia determined by distractibility, bradyphrenia, fragmentary paranoid ideas. Volition was low/absent and activity was characterized by major difficulties in performing daily tasks. Laboratory tests, including thyroid functions, were unremarkable and within normal limits. Computerized brain tomography did not reveal any significant findings.

A few days after admission, when the patient communicated more efficiently, the psychological examination using Symptom Checklist-90 (SCL-90) showed mild levels on psychoticism scale, ambivalence, insecurity, indecision, increased vulnerability in the control and testing of reality, difficulties in differentiating the imaginary from the real, accentuated regression and dependence. The anamnesis, physical, psychiatric and psychologic examination and the lack of somatic pathology led to the diagnostic “Major recurrent depressive disorder, severe depressive episode with psychotic symptoms” according to DSM-5 criteria [ 1 ]. The patient was treated with Escitalopram 10 mg/day, Risperidone 4 mg/day, Valproic acid 600 mg/day, and Clonazepam 0.5 mg/day. A lower dose of Valproic acid was given as a mood stabilizer, and because the patient was underweight the results were positive after 2 weeks of treatment [ 10 , 11 ]. Similarly, 10 mg, instead of 20 mg, of Escitalopram was administered as this drug is an SSRI (selective serotonin reuptake inhibitor) with great efficacy and high doses have been associated with increased agitation and suicidal thoughts in adolescent depression [ 12 ].

During hospitalization, the psychotic symptoms decreased significantly, although the suspicion persisted, as well as the depressed mood. When communication increased and the patient became aware of the disorder, she said that before admission, she had ideas of self-depreciation and guilt and obsessive, aggressive impulses (shouting ugly words, insults, cursing people, included loved ones). At discharge, she had no psychotic symptoms, and her depression improved. The obsessive impulsive symptoms seldom appeared, and psychological examination showed a MADRS score of 20. We did not measure the obsessive-compulsive symptoms since they were manifested during the acute stage of psychotic depression at and before admission, and the patient did not report them. She reported these symptoms in the course of hospitalization when psychosis decreased significantly.

The patient was periodically evaluated in the ambulatory care service. The pharmacologic treatment was well tolerated and consisted of Escitalopram 10 mg/day, Valproic acid 500 mg/day, and Risperidone 3 mg/day for six months following discharge. Subsequently, after the patient’s symptoms improved, Valproic acid was withdrawn due to its reported teratogenic effects [ 13 ]. The patient was also referred to a psychotherapist. According to existential analysis, [ 14 ] psychotherapeutic sessions focused on the fundamental “value of life” in order to accommodate the patient with the present, by structuring her everyday life, by discussing the very structure of each day, easing the burden of tasks (the stress caused by academic papers and exams), and cultivating abilities such as drawing.

During the first six months after discharge, the patient continued to show psycho-emotional lability, paranoid ideation, social anxiety, low sociability, restricted activities (only under parental guidance) that were performed only if she did not feel pressured (i.e., having contact with people that may criticize her) or if the situation involved an effort to concentrate. She behaved childishly with an increased dependence on her mother and showed excessive insecurity regarding self-image that included gestures, words, the meaning of words, and activities.

Six months from the initial hospitalization, the patient re-enrolled in high school (12th grade). Unfortunately, she encountered many difficulties in school and performed poorly due to attention and memory disorders. Moreover, she considered that there were more interesting things to do than school (“there are other more beautiful things in life, I like to know, to discover…”). Secondly, she faced relational difficulties with colleagues and teachers, saying that “people are bad, I feel bad”. Due to these challenges, the patient failed the baccalaureate exam. However, a positive sign during this period was an increased involvement in the domestic activities with her family and regaining her ability to draw. Unfortunately, the patient could not enter a psychotherapy program like cognitive behavioral therapy [ 15 ] or dialectical behavioral therapy [ 16 ] due to psychosocial causes.

Because the patient continued to display impaired functionality in her personal and professional life, after resolving the acute psychiatric disorder, the diagnostic of a Personality disorder was considered [ 1 ]. This was based on the following: marked and persistently unstable self-image, fear of abandonment, emotional instability, chronic feeling of emptiness, and paranoid ideation. Differential diagnostic with Avoidant personality disorder (APD) [ 1 ] was considered since this personality disorder includes many criteria that correspond with the patient’s personality traits such as social inhibition, fear of being criticized, feelings of inadequacy in social relationships.

Currently, the patient manages to carry out house chores, has not been able to focus on her studies for the baccalaureate, no longer feels able to carry out more complex activities alone, does not watch anime anymore, and she draws infrequently, but with a lot of talent. The prognosis is mixed. On the one hand, it is reserved due to some degree of impaired functioning and persistence of obsessive-compulsive symptoms with no possibility for psychotherapy and, on the other hand, the prognosis could turn out to be good due to the relatively good cognitive potential and artistic talent, if allowed psychotherapy and is able to capitalize on her talent.

3. Discussion

This case highlights several important issues and challenges. The medical history showed that the patient had been diagnosed, at an early age, with major recurrent depressive disorder, a severe depressive episode with psychotic symptoms, and OCD accompanied by important social and school dysfunctions. One of the most important challenges of this case was establishing an accurate diagnosis and the right course of treatment. The co-occurrence of severe depressive episodes and OCD in the medical history led us to consider the common association between Bipolar Disorder (BD) and OCD as 50 to 75% of OCD cases are limited to mood episodes in BD. The majority of comorbid OCD cases appear to be secondary to mood episodes, and obsessive-compulsive symptoms occur more often, and sometimes exclusively, during depressive episodes [ 17 ] that can be as high as 75% in BD type II [ 18 ]. Notwithstanding this common association, we made the differential diagnosis between major recurrent depressive disorder with severe depressive episode psychotic elements, BP comorbidity, and OCD, based on the fact that there was no history of manic or hypomanic episode prior to the depressive episode in order to consider the diagnosis of BD. We also considered the patient’s difficulties in performing school activities, the acute and chronic stress linked with her social relations, and hypersensitivity to rejection that can lead to dissociative symptoms [ 19 ]. The patient became gradually more relaxed in the family environment, and her functioning improved significantly. It is known that dissociative states have been linked to maladaptive functioning in BPD [ 20 ] and they are likely to disrupt information processing, learning, and memory on various levels [ 21 ].

In the ambulatory care service, the differential diagnosis between BPD and Avoidant Personality Disorder (APD) was made, given that life history contained multiple negative experiences, including several with sexual content, exclusive focus on the relationships and image, mood swings, infantilism, a tendency to idealism/accusations against others, and, more importantly, immaturity and an extremely fragile self-concept because adolescence was absent from the patient’s life. Avoidance and inhibition are the most persisting and intense patient personality traits, as behavioral acts came from an incompletely developed self. Such a fragile ego that stems from multiple encountered trauma have led to splitting, a common defense mechanism characteristic of BPD [ 9 ].

When considering the diagnostic of BPD and its subtypes, the patient’s history and symptomatology did not reflect the irritable or petulant BPD subtype [ 22 ]. Despite its heterogeneity, BPD is well-characterized by “stable instability”. This means that individuals with this disorder often show instability in the areas of effect, interpersonal relationships, self-image, and behavior [ 23 ]. The current DSM-5 criteria [ 1 ] for BPD include frantic efforts to avoid abandonment, unstable interpersonal relationships alternating between idealization and devaluation, identity disturbance including unstable self-image or sense of self, impulsivity, recurrent suicidal behavior or self-harm, affective instability, chronic feelings of emptiness, inappropriate anger, and transient paranoid ideation or dissociation related to stress.

T. Millon’s 2004 classification [ 22 ] of BPD includes the “discouraged” beside “irritable”, “petulant”, and “self-destructive” types. The discouraged type represents a mixed dependent/avoidant pattern where the attachment/submissiveness is significantly represented. It is characterized by avoiding competition, having humble behavior, constantly preoccupied with insecurity, helplessness, and doubts about one’s abilities. Simple tasks seem very difficult, and life generally seems difficult and “empty”. The individual looks for evidence of affection, and if not found, becomes selfish and angry, followed by rapprochement. The obsessive-compulsive symptoms were present during the severe depressive episode and throughout this patient’s medical history. Studies showed that the comorbidity between BPD and OCD might be seen in patients with BPD [ 24 ]. Although clinical data show that the comorbidity rate of OCD in patients with BPD is less than 10% [ 25 ], more recent studies found a higher than expected overlap between OCD and BPD, reaching rates of up to 15–35% [ 26 ]. The obsessive-compulsive symptoms were isolated, thus ruling out the diagnosis of OCD in comorbidity with Major recurrent depressive disorder, as it did not meet the DSM 5 criteria [ 1 ].

Another important issue to consider in the diagnosis is the co-existence of BPD and the obsessive-compulsive symptoms due to the fact that each of them come from two different nosological group of disorders: cluster B personality disorder vs. cluster C personality disorders. There is, however, a connection between the “discouraged” type that involves features from cluster C personality disorders, that is avoidant, depressive, or dependent [ 27 ]. When considering the anamnesis, the origins of the obsessive-compulsive symptoms did not fit with the Obsessive-Compulsive Personality Disorder (OCPD) from cluster C personality disorder, but instead could derive from perfectionisms [ 28 ], a trait of personality that can, or cannot be part of OCPD. From early childhood and later on, this patient showed perfectionism, which was evident in all activities, but especially in her drawing. Perfectionism is a transdiagnostic process involved in the occurrence and maintenance of many mental health problems such as depression, bipolar disorder, and personality disorders [ 29 ]. While social perfectionism (i.e., thinking that others need self-perfection) is associated with borderline personality (Cluster B), as measured by the Millon Multiaxial Clinical Inventory [ 30 ], a study that used Minnesota Multiphasic Personality Inventory (MMPI) showed that perfectionism was mainly related to paranoid, schizotypal, antisocial, avoidant, compulsive, dependent, and passive-aggressive behavior [ 31 ] (Cluster A and C). From a psychopathological perspective, if Borderline Personality refers to a lack of an integrated self-concept and self-integration in relation to others [ 32 ], negative emotional experiences characteristic of perfectionists (shame and guilt) can be responsible for the observed relationships between perfectionism and identity processes [ 33 , 34 ]. This results in a synergy of similar defense mechanisms, with integration deficits or insufficient ego functions.

4. Conclusions

An 18-year-old female patient presents with Major recurrent depressive disorder, a severe depressive episode with psychotic symptoms. The decreased functionality before and after the depressive episode, together with the clinical symptomatology, life, and family history, led to the diagnostic of Borderline Personality Disorder-discouraged type. The diagnosis of BPD was difficult to make as it does not fall into the typical type of BPD [ 35 ], and it was derived from the association of the features of BPD, cluster B, with social perfectionism, a trait associated with cluster C of PD. Both BPD and perfectionism are associated with problems with self-conception and identity formation. This case report underlines the clinical and psychopathological particularities of BPD that, if not carefully and thoroughly evaluated, may lead to misdiagnosis. Thus far, research on BPD subtypes and their treatment have been sparse and await further validation [ 36 ].

Author Contributions

Conceptualization, L.D.; investigation, L.D. and S.C.S.; writing original draft preparation, S.C.S.; Writing, review and editing, E.A. and M.T.; supervision, G.B. All authors have read and agreed to the published version of the manuscript.

This study was supported by Lucian Blaga University of Sibiu, and Hasso Plattner Foundation research grants LBUS-IRG-2021-07.

Institutional Review Board Statement

All procedures performed in the study were in accordance with the ethical standards of the institution and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed Consent Statement

Written informed consent was obtained from the guardian (i.e., parent) to publish this paper.

Conflicts of Interest

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.