Professional Documents
Culture Documents
net/publication/292677679
CITATIONS READS
33 11,518
4 authors:
Some of the authors of this publication are also working on these related projects:
Processing of Social Participation in Borderline Personality Disorder and Social Anxiety Disorder View project
All content following this page was uploaded by Anna Weinbrecht on 16 October 2017.
REPORTS
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
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
Accordingly, persons with AVPD show a marked avoidance of social interactions, while
perceiving themselves as unwanted and isolated from others. These symptoms are associated
with pronounced impairments in daily life and major societal costs [1, 2]. For instance, recent
findings highlighted considerable impairments in mental (e.g., low self-efficacy, mental distress),
social (e.g., lower level of education, lower income, not in paid work), and somatic (e.g.,
presence of somatic diseases) aspects of individuals with AVPD [3]. Even in comparison to other
personality disorders (PD), AVPD was associated with the highest level of impairment in daily
AVPD is not only among the most impairing PDs but also one of the most prevalent PD.
The median lifetime prevalence is estimated to be 1.7% in community samples and the estimate
of AVPD as a comorbid disorder is about 14.7% in psychiatric outpatients [6, 7]. Despite the
high prevalence and debilitating nature, AVPD is relatively understudied. Most of the available
research focuses on diagnostic aspects, whereas effects of pharmacological treatments are largely
The present review aims to summarize the current state of research in AVPD. In
particular, we will focus on recent findings on (1) diagnostic aspects, such as comorbidity and
stability of symptoms, (2) etiology, and (3) treatment approaches for AVPD.
Diagnostic Aspects
While the publication of the DSM-5 did not result in changes for the diagnostic classification of
AVPD, section III of the DSM-5 includes an alternative proposal for the classification of PDs
[8]. This dimensional classification approach characterizes PDs by two essential features: A.
impairments in personality functioning and B. the presence of pathological personality traits. The
system includes six specific PD diagnoses, one of which is AVPD. With regard to impairments
in the following areas: identity, self-direction, empathy, and intimacy. In addition, this account
In the following sections, we will discuss the relationships between AVPD and other
Social anxiety disorder (SAD) is the most common comorbid diagnosis of AVPD. In a large
AVPD was estimated to be 40% [9], whereas other studies report rates of comorbidity of up to
88% [10] and 100 % [11]. A meta-analysis concluded that AVPD is additionally diagnosed in
46% of individuals with SAD [12]. As a result, numerous articles focus on the delineation of
AVPD and SAD. Many studies support the continuum hypothesis of severity: both disorders
capture clinical representations of social anxiety, however patients with AVPD demonstrate
more severe symptoms and impairments than patients with SAD [for reviews, see 13, 14, 15]
In particular, these studies illustrate that differences in impairments or symptom load
between both disorders are the consequence of varying degrees of social anxiety. Marques and
colleagues [16] examined whether a comorbid AVPD diagnosis yields additional clinically
relevant information in a sample of 326 individuals seeking treatment for generalized social
phobia. They reported that individuals with a comorbid AVPD diagnosis showed higher
impairments across various aspects, such as work, social, or family domains. It should be noted
that the higher severity of social anxiety in individuals with a comorbid AVPD explained these
differences in impairment. Eikenaes and colleagues [17] provided further evidence in favor of
the continuum hypothesis. Individuals with AVPD scored lower on aspects of personality
understand the possible meanings of and causal relations between internal and external
experiences) than individuals with SAD alone. Group differences in these aspects of personality
On the other hand, there are still arguments for a qualitative difference between the
disorders. Sense of inferiority and passivity are examples for possible factors specific to AVPD
[for reviews, see 18, 19]. Paradoxically, support for specific factors of AVPD can also be drawn
from the same studies that provided evidence for the continuum hypothesis. Marques and
colleagues [16] found evidence that emotional guardedness, indicated by the AVPD criteria
‘restraint in intimate relationships’, might be a specific feature of AVPD that is not captured by
the generalized social phobia diagnosis. Eikenaes and colleagues [17] showed that AVPD can be
diagnostic criteria, social fears seem to be more ‘ingrained’ in the self-concept of patients with
AVPD and therefore interfere with more life domains and decisions compared to patients with
SAD. In this line of reasoning, higher emotional guardedness, less self-respect, problems to
express feelings in intimate relationships, and stronger overall avoidance can be considered as
expressions or consequences of extremely high social insecurity and fears. These additional
problems might thus be perceived as specific for AVPD (see Figure 1). The decision of whether
both disorders are expressions of the same construct vastly depends on how widely one defines
and measures social anxiety and the definition of what qualifies as a qualitative difference
between AVPD and SAD. This might explain why after years of extensive research, results on
Previous research has shown substantial overlap among categorical diagnoses of PDs [20].
Although AVPD is among the PDs that are the most likely to be diagnosed solely [7],
comorbidity rates with other PDs are high. For example, Stuart and colleagues [21] reported that
Bachrach, Croon, and Bekker [22] examined the factor structure of PD symptoms in a
sample recruited from a mental health institute. The authors performed a factor analysis of self-
and identified six subscales. However, the subscales were still highly correlated. Interestingly,
two factors explained the correlations among the scales: internalizing personality problems and
comprehensive longitudinal study on the structure of mental disorders by Caspi et al. [23] and
indicates that the high comorbidity of AVPD with other PDs might be due to an underlying latent
A solution to the problem of high comorbidity amongst PDs lies in the application of a
dimensional classification system. Wright et al. [24] provided support for the notion that existing
PDs can be conceptualized as expressions of different personality traits. The authors reanalyzed
data of the Longitudinal Study of Personality Disorders [25] to examine the relationship between
AVPD and basic personality traits using parallel process growth curve modeling. They
negative relationship with the personality traits trajectories of interpersonal dominance and
affiliation and a significant positive relationship to rates of change in neuroticism. Hence, they
provided further evidence for a continuum between normal personality and personality pathology
and replicated previous findings that neuroticism seems to play a crucial role for AVPD [13].
The classification of PDs in a dimensional system has caused lively debate in the development of
the DSM-5 [20]. An alternative model of PDs, describing personalities in a hybrid categorical-
dimensional approach, has been included in the research criteria of the DSM-5 (see above).
Stability of Symptoms
Another problem in the process of conceptualizing PDs in the DSM-5 was the accumulating
evidence that PD symptoms may not be as stable as previously assumed. Initial findings in
AVPD provided evidence for a modest to moderate stability of AVPD symptoms [26, 25, 27,
28]. Recently, Hallquist and Lenzenweger [29] reanalyzed data of the Longitudinal Study of
Personality Disorders to shed light on the stability of PDs over four years. Two groups of young
adults were examined: individuals with possible PD and individuals with no PD at baseline. In
the group with a possible PD at baseline, 41% of the individuals showed subclinical to clinical
AVPD symptoms that remained relatively stable over time. Interestingly, one fifth of individuals
population-based twin study yielded further support for a moderate stability of AVPD symptoms
[30]. In addition, findings from a clinical sample provided also support for moderate rank-order
Taken together, findings suggest that symptoms of AVPD such as feelings of inadequacy,
fears of negative evaluation and patterns of social inhibition characteristic for AVPD remain
relatively stable over time. It is noteworthy that these symptoms can also evolve at later stages in
life.
Etiology
factors. While findings of etiological aspects in AVPD are sparse, the available evidence also
emphasizes the necessity to take genetic and personality factors into account. A population-based
twin study estimated a heritability of .64 for symptoms of AVPD [32]. Based on their findings,
the authors concluded that this genetic influence stabilizes in early adulthood. Environmental
factors contribute to the stability and maintenance of symptoms in AVPD [30]. Further evidence
for a genetic component in the development of AVPD was provided by a multi-generational
family study. In this study, Isomura et al. [33] illustrated that AVPD and SAD cluster in families
due to a proposed genetic factor and that first-degree relatives of individuals with SAD are 3-4
times more likely to have a diagnosis of AVPD. In fact, both disorders were suggested to be
be risk factors for AVPD [e.g., 34, 35]. A cross-sectional comparison of AVPD and SAD
phenomenological differences between both disorders [36]. In this study, group differences
remained stable even after controlling for temperamental factors. Interestingly, the relationship
between retrospectively reported childhood experiences and symptoms of AVPD was mediated
by early maladaptive schemas, such as subjugation, abandonment, and emotional inhibition [37].
Treatment
Empirical research on psychotherapeutic treatment of AVPD started in the late 1980s. Several
treatment approaches were developed and tested. In most cases, treatment in these early studies
Early CBT programs were predominantly delivered in a group format. Treatments included
rehearsal in role-plays, self-image work including video feedback, and social skills training [38-
40]. Results showed moderate to good and mostly stable improvements for individuals with
AVPD. For example, Renneberg et al. [38] reported a recovery rate of 40% assessed by the Fear
Informed by the introduction of cognitive therapy for PDs [41] and the cognitive model
of social anxiety [42], subsequent studies on the treatment of AVPD included more cognitive
individualized model of social fears, the identification of dysfunctional core beliefs, the
development of more adaptive cognitions and beliefs, and behavioral experiments to challenge
“safety behaviors” [e.g., 43, 44, 45]. In a trial comparing individual cognitive therapy to brief
psychodynamic therapy for AVPD, Emmelkamp et al. [43] reported large effect sizes on self-
report measures and a recovery rate of 91% on the SCID-II for the 21 patients randomized to
cognitive therapy. Similarly positive results were reported by Strauss et al. [45] in an
uncontrolled trial of individual cognitive therapy with N = 23 patients with AVPD. In a study
comparing interpersonal to cognitive therapy for social anxiety, two thirds of the patients (28 out
of 44) with comorbid AVPD no longer met diagnostic criteria for AVPD one year after treatment
with no difference between treatment conditions [46]. Treatment dosage in these studies varied,
Psychodynamic Treatment
Most studies examining the effectiveness of psychodynamic approaches encompass patients with
any Cluster C diagnosis and do not focus solely on AVPD [47-49]. In two of these trials,
outcome for AVPD was not reported separately. Barber et al. (1997) reported that 61% percent
sessions. Currently, Leichsenring and Salzer [50] are performing a randomized controlled trial
(RCT) to test a unified protocol for the transdiagnostic psychodynamic treatment of anxiety
disorders, including AVPD. The treatment of this trial is based on the supportive-expressive
Two RCTs so far compared CBT with psychodynamic psychotherapy. Svartberg et al.
[49] found a short-term dynamic psychotherapy and CBT to be equally effective for Cluster C
PDs. Emmelkamp et al. [43] compared 20 weekly sessions of CBT (based on the cognitive
model of social anxiety from Clark and Wells) to brief dynamic psychotherapy and a waitlist
condition. In contrast to the results of Svartberg and colleagues, the 21 AVPD individuals in the
CBT condition showed significantly larger decrease in diagnostic criteria (SCID-II) and
improvement on self-report measures in comparison with 23 patients treated with brief dynamic
psychotherapy and the waitlist condition (N = 18). These results were maintained at 6 months
follow-up.
Schema therapy
Schema therapy focuses on working with schema modes, defined as momentary mind states
consisting of cognitions, emotions, and behaviors, which evolved as the result of unsatisfied
basic needs and corresponding developed coping styles [52]. This approach integrates cognitive-
behavioral, psychodynamic, and Gestalt therapy techniques. In treating AVPD, the most relevant
schema modes are the Lonely Child mode which is characterized by feelings of loneliness,
unworthiness and being unloved, the Avoidant Protector mode, in which situational avoidance is
activated, and the Detached Protector mode which is characterized by avoidance of inner needs,
emotions and emotional contact. Furthermore, a Punitive Parent mode is active in which the
feeling that oneself deserves punishment or blame is assumed to be activated [53]. In a first trial,
Weertman, Arntz [54] provided preliminary evidence for the effectiveness of schema therapy
The same research group [55] compared individual schema therapy (50 sessions) to
clarification-oriented psychotherapy and treatment as usual (TAU) for patients with a Cluster C
diagnosis (N = 323 participants, N = 163 with AVPD). The authors reported a higher recovery
rate for schema therapy compared to clarification-oriented and TAU for Cluster C. Over 80% of
the patients treated with schema therapy recovered. Recovery was defined as not meeting criteria
for any PD, assessed with the SCID-II by blinded independent interviewers. The authors did not
find a significant effect of primary PD diagnosis on outcome, which indicated that 50 sessions of
individual schema therapy delivered over a two-year period led to improvement in AVPD
symptoms as well as on secondary outcome measures. Results were stable at three-year follow-
up. Schema therapy delivered in a group setting was tested in a small pilot study with a mixed
PD sample [56]. Results showed that four out of the six patients diagnosed with AVPD
Taken together, schema therapy shows promising potential for treating AVPD. However,
it remains unclear whether it actually provides benefit over traditional CBT. Greeven and
colleagues [57] are currently conducting a RCT comparing group schema therapy to group CBT
for individuals with SAD and comorbid AVPD. Planned closing date is in autumn, 2018.
Other recent approaches that showed potential for treating AVPD in single case studies include
interpersonal psychotherapy [61]. All approaches are based on theoretical models on how AVPD
symptoms develop and should best be treated. Whether one of these approaches proves superior
Quite a few studies examined whether AVPD diagnosis predicts outcome for treatment of SAD
[62-66]. Analyses mainly showed that individuals diagnosed with SAD and comorbid AVPD
report similar change rates in social anxiety symptoms compared to individuals without a
comorbid AVPD diagnosis. However, as AVPD patients start off at a higher level of severity,
they also terminate treatment on a more dysfunctional level than individuals without AVPD.
These results are in line with the continuum hypothesis of social anxiety as discussed above.
There are not many treatment studies that focus exclusively on patients with AVPD. Early
studies demonstrated that patients with AVPD responded well to primarily behavioral techniques
[38-40]. These results were followed by very few more recent trials, integrating more cognitive
treatment elements [46, 43, 45]. Brief psychodynamic treatments were tested in two RCTs, with
contradictory results regarding their efficacy compared to CBT [43, 49]. More recently, schema
In 1985, Liebowitz and colleagues wrote an article on “social phobia – review of a neglected
anxiety disorder”. Since then, research on SAD increased significantly and in 2015 etiology,
maintenance, and treatment of SAD are well investigated. Research on AVPD, on the other hand,
is still scarce. Especially in light of its high prevalence and severe associated impairments,
social anxiety and other PDs. In the DSM-5 diagnostic criteria were not changed and thus the
problem of high comorbidity between AVPD and other mental disorders remains. The alternative
model in the supplementary material of DMS-5 provides a dimensional approach and hence
pathology traits might help to develop instruments to assess specific AVPD traits. This way, the
anhedonia, intimacy avoidance) seem plausible, more research is needed to justify this selection
Compared to SAD or borderline personality disorder there are only few studies on the
efficacy and effectiveness of psychotherapeutic treatment for AVPD. Even though effect sizes
and recovery rates for the treatment of AVPD are promising and seem comparable to the
treatment of SAD, large RCTs focusing on treatment of AVPD are rare. At this point CBT and
schema therapy show the strongest empirical evidence for the treatment of AVPD.
The paucity of relevant clinical trials on AVPD patients could at least partly be explained
by the close relationship of SAD and AVPD. As patients with AVPD are successfully included
in trials testing treatments for SAD, there may be less motivation and more problems to generate
large patient groups to focus research solely on AVPD. However, in our opinion, the plain
adaption of SAD protocols for the treatment of AVPD does not suffice, mainly because of the
strong avoidance that these patients show. For example, cognitive therapy for SAD puts strong
emphasis on experimenting with safety behaviors (e.g., like avoiding eye contact). However,
patients with AVPD may be too consumed by their anxiety to be able to perform the required
task (reduce safety behavior) or they might not even enter the role-play situation because of their
extreme avoidance. Protocols should also include brief exercises and role-plays to build up social
skills. In a study on generalized social phobia where 75% of the patients also met diagnostic
criteria of AVPD, Herbert and colleagues [68] demonstrated the beneficial effect of adding social
As outlined above, treatment lengths vary greatly between different studies. Schema
therapy delivered in the trial by Bamelis et al. (2014) lasted for 50 sessions spread out over more
than a year. Rees and Pritchard (2015) question the necessity of prolonged treatment duration in
AVPD and present the cases of two patients successfully treated in 12 sessions of cognitive
therapy. However, many authors argue that it takes more time to achieve structural or emotional
changes in AVPD [69, 56]. Results show no consistent trend in favor of longer or shorter
treatments, and additional empirical research is needed. Furthermore, future research should
target the lack on empirical research examining the relationship between number of treatment
settings with promising results for both formats. So far, there is no evidence on which format is
superior in the treatment of AVPD. A group setting yields economic advantages and offers the
possibility for role-plays as well as behavioral experiments. In our research group, we have
observed a steeper decline of symptoms after patients with AVPD participated in a CBT group
for social anxiety. In the clinical practice, we favor accompanying single sessions to ensure that
avoidance decreases and patients are well prepared for group participation. Future research has to
clarify if a combination of individual single session and group therapy is most beneficial for
In light of prevalence rates, societal costs, and the current state of research, it needs to be stated
that AVPD qualifies as a neglected disorder. Up until now, the available research has primarily
focused on the delineation of SAD and AVPD. Future research should shift its focus to more
These might also serve as important variables for assessing the outcome of different
psychotherapeutic approaches for AVPD. With regard to the treatment of AVPD, the present
review presents an urgent call for more research to identify appropriate therapeutic techniques as
well as the appropriate treatment dose and setting for targeting the maladaptive schemas and
elaborated avoidance patterns. Recent findings are too limited to provide a clear recommendation
for the treatment of AVPD. In fact, recent attempts of the Cochrane Library to summarize
beneficial and adverse effects of therapeutic interventions in AVPD failed due to difficulties to
In this longitudinal study, the rates of change in avoidant personality disorder symptoms
affiliation, and neuroticism). This supports the proposition that personality disorders can
be conceptualized as expressions of normal personality traits and stresses the crucial role
Results indicated that avoidant personality disorder can develop at a later stage of life and
This longitudinal twin study provided support that genetic factors contribute more to the
Hopwood, Morey, Donnellan, Samuel, Grilo, McGlashan, Shea, Zanarini, Gunderson, &
Skodol (30)
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.
This pilot study determined the effects of group schema therapy in patients with
2. Ullrich S, Farrington DP, Coid JW. Dimensions of DSM-IV personality disorders and life-
3. Olsson I, Dahl AA. Avoidant personality problems--their association with somatic and mental
2012;53(6):813-21.
4. 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
5. 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
2009;50(6):624-32.
8. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5 ed.
9. Cox BJ, Pagura J, Stein MB, Sareen J. The relationship between generalized social phobia and
2009;26(4):354-62.
10. Hofmann SG, Newman MG, Ehlers A, Roth WT. Psychophysiological differences between
11. Herbert JD, Hope DA, Bellack AS. Validity of the distinction between generalized social
Disord. 2013;145(2):143-55.
13. Alden LE, Laposa JM, Taylor CT, Ryder AG. Avoidant personality disorder: current status
14. Bogels SM, Alden L, Beidel DC, Clark LA, Pine DS, Stein MB et al. Social anxiety disorder:
15. Reich J. Chapter 2 - Avoidant Personality Disorder and its Relationship to Social Anxiety
Disorder. In: Hofmann SG, DiBartolo PM, editors. Social Anxiety (Third Edition). San Diego:
16. 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
patients with avoidant personality disorder and social phobia. J Pers Disord. 2013;27(6):746-63.
18. Rettew DC. Avoidant Personality Disorder, Generalized Social Phobia, and Shyness: Putting
the Personality Back into Personality Disorders. Harvard Review of Psychiatry. 2000;8(6):283-
97.
19. Sanislow CA, Bartolini EE, Zoloth EC. Avoidant personality disorder. In: Ramachandran
VS, editor. Encyclopedia of Human Behavior. 2 ed. San Diego: Academic Press; 2012. p. 257-
66.
20. Skodol AE, Bender DS, Morey LC, Clark LA, Oldham JM, Alarcon RD et al. Personality
21. Stuart S, Pfohl B, Battaglia M, Bellodi L, Grove W, Cadoret R. The cooccurrence of DSM-
22. 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.
23. 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
24. Wright AG, Pincus AL, Lenzenweger MF. A parallel process growth model of avoidant
25. Lenzenweger MF. Stability and change in personality disorder features: the Longitudinal
26. Grilo CM, Sanislow CA, Gunderson JG, Pagano ME, Yen S, Zanarini MC et al. Two-year
27. 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
stability and latent structure of the DSM-IV schizotypal, borderline, avoidant, and obsessive-
29. Hallquist MN, Lenzenweger MF. Identifying latent trajectories of personality disorder
symptom change: growth mixture modeling in the longitudinal study of personality disorders. J
30. Gjerde LC, Czajkowski N, Roysamb E, Ystrom E, Tambs K, Aggen SH et al. A longitudinal,
31. 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.
32. 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
based, multi-generational family clustering study of social anxiety disorder and avoidant
34. 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
35. Meyer B, Carver CS. Negative childhood accounts, sensitivity, and pessimism: a study of
37. Carr SN, Francis AJ. Early maladaptive schemas and personality disorder symptoms: An
38. Renneberg B, Goldstein AJ, Phillips D, Chambless DL. Intensive Behavioral Group
39. Alden L. Short-Term Structured Treatment for Avoidant Personality-Disorder. J Consult Clin
Psychol. 1989;57(6):756-64.
40. 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.
41. Beck AT, Freeman AM. Cognitive therapy of personality disorders. New York, NY, US:
42. 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:
43. Emmelkamp PM, Benner A, Kuipers A, Feiertag GA, Koster HC, van Apeldoorn FJ.
44. Rees CS, Pritchard R. Brief cognitive therapy for avoidant personality disorder.
45. 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.
46. Borge FM, Hoffart A, Sexton H, Clark DM, Markowitz JC, McManus F. Residential
cognitive therapy versus residential interpersonal therapy for social phobia: a randomized
47. 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.
48. Barber JP, Morse JQ, Krakauer ID, Chittams J, Crits-Christoph K. Change in obsessive-
49. 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.
50. Leichsenring F, Salzer S. A unified protocol for the transdiagnostic psychodynamic treatment
dynamic psychotherapy. New York, NY, US: Basic Books; 1991. p. 110-36.
52. Young JE, Klosko JS, Weishaar ME. Schema therapy: A practitioner's guide. New York,
therapy for personality disorders: a controlled study contrasting methods focusing on the present
55. 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.
56. Skewes SA, Samson RA, Simpson SG, van Vreeswijk M. Short-term group schema therapy
57. Group schema therapy versus group cognitive behavioral therapy for social anxiety disorder
[Internet]. NTR number: NTR3921. 2013. Available from: Available online at:
http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=3921. Accessed:
Metacognitive interpersonal therapy for co-occurrent avoidant personality disorder and substance
59. Pos AE. Emotion Focused Therapy for Avoidant Personality Disorder: Pragmatic
Psychotherapy. 2014;44(2):127-39.
60. Chan CC, Bach PA, Bedwell JS. An Integrative Approach Using Third-Generation
2015:1-16.
61. Gilbert SE, Gordon KC. Interpersonal Psychotherapy Informed Treatment for Avoidant
63. 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.
64. Hope DA, Herbert JD, White C. Diagnostic Subtype, Avoidant Personality-Disorder, and
1995;19(4):399-417.
65. 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.
66. 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
67. Liebowitz MR, Gorman JM, Fyer AJ, Klein DF. Social phobia. Review of a neglected
68. 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
69. 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
70. Ahmed U, Gibbon S, Jones Hannah F, Huband N, Ferriter M, Völlm Birgit A et al.
71. Ahmed U, Gibbon S, Jones Hannah F, Huband N, Ferriter M, Völlm Birgit A et al.
Figure 1
Proposed relationship between social anxiety and additional problems, such as harm avoidance,
or intimacy avoidance, in patients with avoidant personality disorder compared to social anxiety