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Treating Avoidant Personality Disorder: The Case of Paul

Article  in  Journal of Cognitive Psychotherapy · December 2007

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 Journal of Cognitive Psychotherapy: An International Quarterly
Volume 21, Number 4 • 2007

CASE STUDY

Treating Avoidant Personality Disorder:

The Case of Paul

Stefan G. Hofmann, PhD

Boston University

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 specifi-
cally 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.

Keywords: avoidant personality disorder; cognitive-behavior therapy; exposure therapy; self-

perception; self

A
lthough cognitive-behavior therapy is one of the most efficacious forms of psychological
intervention for severe social anxiety, the response rates of these approaches are typically
less than 60% at postacute treatment with dropout rates typically ranging between 10%
and 20% (e.g., Gould, Buckminster, Pollack, Otto, & Yapp, 1997). The treatment outcome lit-
erature further suggests that avoidant personality disorder (APD), which is often comorbid with
generalized social phobia, may be predictive of poor psychotherapy outcome (Alden & Capreol,
1993; Feske, Perry, Chambless, Renneberg, & Goldstein, 1996). Other studies, however, have not
found that APD is a significant moderator of treatment change (Brown et al., 1995; Dreessen & AQ1
Arntz, 1998; Hofmann, Newman, Becker, Taylor, & Roth, 1995, Hope, Herbert, & White, 1995;
Mersch, Jansen, & Arntz, 1995; Van Velzen, Emmelkamp, & Scholing, 1997).
The psychopathology literature suggests that individuals with severe social anxiety desire to
make a particular impression on others but doubt that they will be able to do so (Leary, 2001),
which is associated with social apprehension and self-focused attention (Heinrichs & Hof-
mann, 2001). Vulnerable individuals further exaggerate the potential social costs (Foa, Franklin,
Perry, & Herbert, 1996; Hofmann, 2004), and they assume that they are in danger of behaving in
an inept and unacceptable fashion, which will result in disastrous consequences (Clark & Wells,
1995). In addition to these disorder-specific aspects of social anxiety, individuals with APD, as

© 2007 Springer Publishing Company 343

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 344 Hofmann

acknowledged by the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV)
(American Psychiatric Association, 1994), often show severe deficits in interpersonal relation-
ships and their social environment. Therefore, cognitive-behavioral therapies that combine inter-
vention strategies that specifically target the social context, in addition to maladaptive cognitions
that target negative self-perception, should result in a maximum degree of improvement. The
case of Paul illustrates such an adaptation of cognitive-behavioral strategies to treat severe APD.

CASE PRESENTATION
Presenting Problem
Paul was a 24-year-old white male. He was a medium-sized, attractive male who was appropri-
ately dressed for both interviews. He was cooperative and appeared to be answering questions
candidly throughout the interviews. His affect was friendly. He was well articulated but spoke
very softly and avoided eye contact with the interviewer. There was no evidence of psychotic
thought processes, and his mental status was normal.
He was self-referred for treatment at a large anxiety clinic located in downtown Boston,
Massachusetts, USA. The main reason for which Paul sought help was for debilitating and per-
vasive social anxiety that he had been experiencing since middle school. Paul reported that he
would avoid any social contact with other people and even feels restraint when interacting with
his parents and other relatives. He stated that he desires companionship but is unwilling to get
involved with people because he is preoccupied with being criticized or rejected. When asked
why he is seeking help at the present time, he noted that he wanted to move out of his parents’
home, get a job, have relationships, and lead a normal life. It was apparent that Paul showed a
clear readiness for change and had clear short-term and long-term goals for himself. However,
he viewed his competence to implement such changes as insufficient. Paul was offered group
treatment at the clinic, which is the standard treatment for social phobia. However, he refused
to participate because he was too fearful of interacting with other group participants.

History
He reported that he dropped out of high school in 10th grade when he was asked to give a presen-
tation in front of his class. In order to avoid this assignment, he ran away from home and spent
the night in a local park. When the police found him the next day, his parents told him that he
did not have to return to school. Since that time, Paul had been living at home with his parents.
He did not return back to school and did not see any of his classmates again. Paul described the
relationship with his family as difficult. Both of his parents were born and raised in Greece and
emigrated to the United States when they were in their 20s. Paul’s family spoke Greek at home
and followed Greek traditions. He described his father as politically conservative, domineer-
ing, authoritarian, and overinvolved and his mother as submissive and conflict avoidant. Paul
reported having two older sisters. He considered his second-oldest sister to be his best friend.
He reported that he speaks to her once a week for a few minutes on the phone. His family was
unaware of the fact that he was seeking treatment for his social anxiety.
In addition to social anxiety, Paul also reported that he feels depressed and that he wor-
ries excessively about various minor matters. Paul stated that, because of his problems, he has
occasional thoughts about suicide but denied any intent or plan. Paul had never received any
psychological or pharmacological treatments.

DSM-IV Diagnoses
As part of the regular intake procedure, Paul underwent a structured diagnostic interview, the
Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV; DiNardo, Brown, & Barlow, 1994).

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 Treating Avoidant Personality Disorder 345

A second interview by an independent clinician was conducted 1 week later. The two interviews
yielded consistent results, and senior clinicians agreed with the diagnostic assessment. The ADIS-IV
screens for all axis I mood and anxiety disorders and assigns a clinical severity rating (CSR) on a
scale from 0 (no distress/interference) to 8 (extreme distress/interference). A CSR rating of 4 or
higher marks the clinical threshold.
Paul was the most severe case of social phobia/APD that was ever seen at the clinic (and there
are approximately 100 new admissions of patients with social phobia every year since 1996).
He met criteria for the following axis I diagnoses: social phobia, generalized subtype (CSR: 8);
generalized anxiety disorder (CSR: 5); and depressive disorder not otherwise specified (CSR: 5).
Furthermore, he met criteria for APD (CSR: 8) on axis II and scoliosis (S-shaped side-to-side spi-
nal curve) on axis III. The raters coded problems related to the social environment and occupa-
tional problems on axis IV and assigned a global assessment of functioning score of 45 (current
and past year) on axis V (serious symptoms or any serious impairment in social, occupational,
or school functions).

CASE CONCEPTUALIZATION AND TREATMENT PLAN

View of Self
During the interview, Paul made a number of remarks suggesting that he had a distorted image
of himself. Although his attractiveness was above average, he saw himself as physically unappeal-
ing, socially inept, and inferior to others. Therefore, the primary treatment goal was to enhance
Paul’s view of himself as a social object.

Financial Independence and Living Environment

Paul’s overprotective and overinvolved parents had an essential role in his psychopathology.
Therefore, it was questionable whether significant changes in Paul’s social anxiety could be
achieved without changing his living environment, improving his independence, and limiting
the contact with his family. Finding a job, obtaining a credit card and driver’s license, and mov-
ing out of his parent’s home and into his own place were consequently important treatment
goals. This would also provide a number of opportunities for in vivo exposure practices.

Interpersonal Relationships
Paul feared and avoided social contact but at the same time greatly suffered from social isola-
tion. Establishing and widening Paul’s social network was, therefore, an important intermediate
treatment goal. During treatment, Paul revealed that he believed that he was homosexual. There-
fore, an important long-term treatment goal was to establish a close relationship with another
homosexual male.

TREATMENT
Timing of Therapy Sessions
Paul received in total 27 hourly individual treatment sessions. Sessions 1 to 20 were scheduled
weekly, sessions 20 to 24 monthly, and sessions 24 to 27 every 3 months. A 1-year follow-up
assessment was scheduled to ensure stability of the treatment changes.

View of Self
Paul’s perception of his self—and particularly his view of his bodily appearance—showed many
similarities to body dysmorphic disorder. Paul did not meet this additional diagnosis because

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 346 Hofmann

his social phobia fully accounted for these concerns. On further exploration, he believed that his
nose was too big and crooked. As a result, he avoided looking at himself closely in the mirror in
the bathroom or at other locations.
In order to correct Paul’s distorted body image, the therapist brought a mirror to the session
and asked Paul to look into a mirror and describe himself. This exercise was very distressing to
him. He reported a number of self-deprecating self-statements and cried during the exercise.
Beginning session 3, Paul was therefore repeatedly exposed to his mirror image in session and
as part of his homework assignments in order to become comfortable with his self-presentation.
Because of the effects of the mirror presence on his level of distress, the therapist also utilized the
mirror exposure again when Paul prepared himself for a job interview (session 6). During this
exercise, he was asked to role-play a job interview while looking at himself in the mirror. After
Paul became more comfortable with his mirror image, the therapist brought a video camera into
session, videotaped him while he was giving an impromptu speech, and examined his predicted
and actual (videotaped) social performance (session 7).
In order to gather further information on Paul’s self-perception, the therapist presented
Paul with socially threatening words and asked Paul to write down his thoughts in response
to these words. The word list was taken from a previous information processing experiment.
Examples of the stimulus words were “Humiliation,” “Foolish,” and “Rejected” (sessions 3 to 6).
Paul’s response to these words was used to identify and challenge some of Paul’s maladaptive
cognitions related to social phobia. It became apparent that most of his concerns in social
situations were associated with heightened self-consciousness and negative self-perception. In
addition, his responses indicated that he expressed unrealistically high expectations about social
norms, expectations about his own behaviors in social situations, and expectations about the
outcome of social situations. After discussing cognitive countering strategies, Paul was instructed
to repeatedly read the list of words and challenge his maladaptive thoughts triggered by the
stimulus words.
As part of the between-session homework assignments, Paul was instructed to perform a
number of very specific tasks to challenge his assumptions about his social standards, his perfec-
tionism related to social performances, and his estimation of social consequences in case of social
mishaps. These tasks included exchanging a pair of pants (session 7), returning to a barbershop
shortly after he got a haircut to ask the barber to correct a minor mistake (session 8), going to
job interviews (starting session 9), joining a gym (session 12), asking coworkers out for lunch or
for other social events (starting session 13), asking his boss about his health plan (session 14),
going to a restaurant by himself and sitting at the bar (session 15), joining a basketball club (ses-
sion 17), coming to session and to work at least 10 minutes late (session 17), talking to a person
at a food court (session 18), asking his boss for a promotion (session 20), wearing a flashy tie to
work (session 22), and, finally, dating another male whom he meets through an Internet dating
service (session 23).

Financial Independence and Living Environment

It became apparent from the beginning of therapy that Paul’s family relationship and his living
environment led to the maintenance of his social anxiety. Since Paul’s social anxiety surfaced, his
parents—and particularly his father—isolated Paul socially. In fact, Paul’s dependence on them
seemed to have an important role in the family dynamic, perhaps enhancing the relationship
between his parents. Therefore, given Paul’s relationship to his parents and its effect on his social
anxiety, an important intermediate treatment goal was to foster Paul’s financial independence by
finding a job in order to move out of his parents’ home and into his own apartment.
The goal to obtain financial independence and to broaden his social network was aggres-
sively pursued as soon as Paul felt comfortable engaging in some social contact. The treatment

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 Treating Avoidant Personality Disorder 347

highlights included the following: discussing how to fill out an application form (session 5;
his résumé showed some gaps that were difficult to explain), role-playing of job interviews
(session 6), and filling out one job application every day (homework for session 8). By session 9,
he got a job at a radio store. By session 10, he applied for his own credit card and started making
plans to move out of his parents’ house within the next 6 months. By session 15, he took on a sec-
ond job as a waiter on weekends. By session 17, he began working with a real estate agent to find
an apartment. By session 23, he signed his new lease and told his boss that he would start working
at another radio store unless he got a raise (he actually did get the raise but then went back to
school to finish his high school diploma and obtain a degree in computer programming).

Interpersonal Relationships
In session 8, Paul stated that he was homosexual but that he had never been in a close interper-
sonal or romantic relationship. He expressed a desire to date other men and suggested including
this as a treatment goal. Through his work and by joining sports clubs, he was able to gradually
build and increase his circle of friends. By session 24, he began an intimate relationship with a
50-year-old man whom he met through an Internet site. By session 27, he broke up with him and
started dating a person of his own age and developed a circle of friends. The relationship with his
parents remained problematic.

Self-Report Measures and Changes in Diagnostic Status

In order to track Paul’s progress, he was given the Social Phobia and Anxiety Inventory (SPAI;
Turner, Beidel, Dancu, & Stanley, 1989) at approximately every third session and at pretest, post-
test, and 1-year follow-up. Turner et al. (1989) suggested that an SPAI (total) cutoff score of 80
is optimal for identifying individuals with social phobia among a sample of clinic patients with
anxiety disorders. Figure 1 shows that the intervention led to a significant drop within the first
3 months of therapy (by session 11) from the clinical to a nonclinical range. These gains were

FIGURE 1. Paul’s treatment changes in the Social Phobia and Anxiety Inventory (total score).

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 348 Hofmann

maintained at the 1-year follow-up. Paul underwent a second diagnostic assessment at the end
of treatment by a blinded clinician as part of a regular clinic procedure. He no longer met any
DSM-IV axis I or II criteria.

DISCUSSION
The case of Paul illustrates that APD, a pervasive and debilitating problem, can be treated within
a relatively short period of time by using cognitive-behavioral techniques designed to enhance the
person’s self-perception as a social object. Therefore, this case is consistent with the results of other
studies suggesting that APD is not a predictor for poor treatment outcome (Brown et al., 1995;
Dreessen & Arntz, 1998; Hofmann et al., 1995, Hope et al., 1995; Mersch et al., 1995; Van Velzen
et al., 1997). In fact, APD was very responsive to cognitive-behavioral intervention. However, the
treatment strategies that were used in this study deviated from traditional cognitive-behavioral
strategies outlined in the various treatment protocols. In addition to the cognitive biases related
to social anxiety, the intervention targeted a much broader area of Paul’s symptomatology. Specifi-
cally, Paul’s social anxiety was not only seen as a result of cognitive biases related to social situations
but was also conceptualized as a context-dependent phenomenon that is colored by his culture,
sexual orientation, ethnicity, demographic variables, religious beliefs, and social background.
In sum, the present case shows that cognitive interventions that go beyond the limits of the
DSM-IV category of social phobia and the traditional techniques to target cognitive biases can
result in potent and long-lasting treatment effects. Future treatments for APD and severe social
anxiety should consider the larger social context that determine the person’s perceived social
norms, social status, and interpersonal relationships, which in turn determine the individual’s
self-perception as a social object. Considering these variables in treatment can translate into
extremely powerful intervention strategies.

REFERENCES
Alden, L. E., & Capreol, M. J. (1993). Avoidant personality disorder: Interpersonal problems as predictors of
treatment response. Behavior Therapy, 24, 357–376.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.).
Washington, DC: Author.
Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. G. Heimberg, M. R. Liebowitz,
D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment and treatment (pp. 69–93). New
York: Guilford Press.
DiNardo, P. A., Brown, T. A., & Barlow, D. H. (1994). Anxiety Disorders Interview Schedule for DSM-IV
(ADIS-IV). Graywind Publications.
Dreessen, L., & Arntz, A. (1998). The impact of personality disorders on treatment outcome of anxiety
disorders: Best-evidence synthesis. Behaviour Research and Therapy, 36, 483–504.
Feske, U., Perry, K. J., Chambless, D. L., Renneberg, B., & Goldstein, A. J. (1996). Avoidant personality dis-
order as predictor for severity and treatment outcome among generalized social phobics. Journal of
Personality Disorder, 10, 174–184.
Foa, E. B., Franklin, M. E., Perry, K. J., & Herbert, J. D. (1996). Cognitive biases in generalized social phobia.
Journal of Abnormal Psychology, 105, 433–439.
Gould, R. A., Buckminster, S., Pollack, M. H., Otto, M. W., & Yap, L. (1997). Cognitive-behavioral and
pharmacological treatment for social phobia: A meta-analysis. Clinical Psychology: Science and Practice,
4, 291–306.
Heinrichs, N., & Hofmann, S. G. (2001). Information processing in social phobia: A critical review. Clinical
Psychology Review, 21, 751–770.

3072-030d-006.indd 348 9/28/2007 1:22:59 AM

 Treating Avoidant Personality Disorder 349

Hofmann, S. G. (2004). Cognitive mediation of treatment change in social phobia. Journal of Consulting
and Clinical Psychology, 72, 392–399.
Hofmann, S. G., Newman, M. G., Becker, E., Taylor, C. B., & Roth, W. T. (1995). Social phobia with and
without avoidant personality disorder: Preliminary behavior therapy outcome findings. Journal of
Anxiety Disorders, 9, 427–438.
Hope, D. A., Herbert, J. D., & White, C. (1995). Diagnostic subtype, avoidant personality disorder, and
efficacy of cognitive-behavioral group therapy for social phobia. Cognitive Therapy and Research, 19,
399–417.
Leary, M. R. (2001). Social anxiety as an early warning system: A refinement and extension of the self-
presentation theory. In S. G. Hofmann & P. M. DiBartolo (Eds.), From social anxiety to social phobia:
Multiple perspectives (pp. 321–334). Boston: Allyn & Bacon.
Mersch, P. P. A., Jansen, M. A., & Arntz, A. (1995). Social phobia and personality disorder: Severity of com-
plaint and treatment effectiveness. Journal of Personality Disorders, 9, 143–159.
Turner, S. M., Beidel, D. C., Dancu, C. V., & Stanley, M. A. (1989). An empirically derived inventory to
measure social fears and anxiety: The Social Phobia and Anxiety Inventory. Psychological Assessment,
1, 35–40.
Van Velzen, C. J. M., Emmelkamp, P. M. G., & Scholing, A. (1997). The impact of personality disorders on
behavioural treatment outcome for social phobia. Behaviour Research and Therapy, 35, 889–900.

Correspondence regarding this article should be directed to Stefan G. Hofmann, PhD, Department of Psychology,
Boston University, 648 Beacon Street, 6th Floor, Boston, MA 02215. E-mail: shofmann@bu.edu

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 AUTHOR QUERY
AQ1: Author: Please add Brown et al. to the References.

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