Agency in avoidant personality disorder: a narrative review

Objectives

Avoidant personality disorder (AvPD) is a highly prevalent personality disorder, especially in clinical settings, yet scarcely researched. People diagnosed with AvPD have severe impairments in functioning and suffer greatly, yet we still lack meta-analytic evidence for therapy and only a few RCTs are conducted. Patient factors are the most important for outcome in therapy, in general. Lack of agency might be a core deficit in people diagnosed with AvPD. Their conditions might be improved if we understand their agency better. We review previous research regarding psychological mechanisms and interpersonal relationships that facilitate or hinder agency in AvPD in daily life and psychotherapy.

Methods

Summarizing original literature in a narrative review with reflexive thematic analysis.

Results

People diagnosed with AvPD seem to have significant impairments in their sense of agency due to a lack of emotional awareness, an overweight of inhibiting vs. activating emotions, and difficulties regulating emotions. Difficulties also seem related to high levels of attachment avoidance and fear, creating strong ambivalence in social needs, in addition to a strong tendency to subordinate to others. A weak sense of self with a poor narrative, self-doubt, and harsh self-critique makes a reflexive and intentional stand increasingly difficult for these people.

Conclusion

This review gives a clinically meaningful understanding of core strengths and deficits in the personality functioning of AvPD that can help clinicians map out important therapeutic work, identify barriers to client-agency in therapy, and work through relational difficulties in the therapeutic alliance.

Which are the best questionnaires to longitudinally evaluate mindfulness skills in personality disorders?

BACKGROUND

Personality disorders (PDs) are severe mental illnesses, characterized by inflexible and enduring response patterns in a broad range of personal and social situations. With the aim of identifying effective and evidence-based interventions, in the last decades we observed a flourishing of the so-called "thirdwave" cognitive-behavioural therapies, where mindfulness appears as relevant factor in promoting individual well-being and treatment response. In this regard, several authors tried to develop new instruments that enable to measure mindfulness skills, such as the Kentucky Inventory of Mindfulness Skills (KIMS), the Five Facet Mindfulness Questionnaire (FFMQ) and the Philadelphia Mindfulness Scale (PHLMS). The aim of this review is to provide new insights about the mindfulness questionnaires currently used in longitudinal studies in PDs by providing a benchmark for future studies evaluating mindfulness changes associated to therapeutic interventions.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search in PubMed was performed. Three reviewers conducted the data extraction. Longitudinal studies on PDs evaluating mindfulness skills through a validated questionnaire were selected. Ten studies met the selection criteria.

RESULTS

The majority of the studies reviewed (N=7) detected an increase in mindfulness skills (4 rated with FFMQ, 2 KIMS, and 1 Philadelphia Mindfulness Scale). Finally, from the selected studies mindfulness changes were also associated with clinical amelioration.

LIMITATIONS

Few studies evaluate male patients and PDs other than borderline personality disorder.

CONCLUSION

Although mindfulness is a complex construct to operationalize, the considered questionnaires emerged as useful instruments for clinicians to detect changes in mindfulness abilities. In particular, currently the FFMQ appears as the most suitable measure.

Lived Experience of Treatment for Avoidant Personality Disorder: Searching for Courage to Be

Objective: To inquire into the subjective experience of treatment by persons diagnosed with avoidant personality disorder.

Methods: Persons with avoidant personality disorder (n = 15) were interviewed twice, using semi-structured in-depth interviews, and the responses subject to interpretative-phenomenological analysis. Persons with first-hand experience of avoidant personality disorder were included in the research process.

Results: The super ordinate theme emerging from the interviews, “searching for courage to be” encompassed three main themes: “seeking trust, strength, and freedom,” “being managed,” and “discovering the possibility for change and development.” The main theme, “being managed,” included the subthemes: “getting a diagnosis,” “receiving medication,” and “attending therapy.”

Conclusion: Although this may not be specific to avoidant personality disorder, the findings highlight the importance of being met inter-subjectively as a person with intentionality and agency, even when one does not feel like one. The importance of establishing an emotional bond and emergent trust for open therapeutic collaboration, learning, and becoming able to build courage to begin to approach that which one fears is emphasized.

Avoidant Personality Disorder: a Current Review

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.