What Aspect of Dialectical Behavior Therapy Relates to Psychodynamic Theory?

International Periodical of Psychology and Psychoanalysis

A Review of Characteristics and Treatments of the Avoidant Personality Disorder. Could the DBT be an Option?

Antonio Drago^one*, Cristina Marogna^two and Hans Jørgen Søgaardⁱ

^oneInstitut for Klinisk Medicin, Aarhus University - Psykiatrisk Forskningsenhed Belong, Herning, Denmark
²Department of Philosophy, Folklore, Education and Applied Psychology (FISPPA), Padua University, Padua, Italia

^*Respective writer: Antonio Drago, Institut for Klinisk Medicin, Aarhus University - Psykiatrisk Forskningsenhed Vest, Regionspsykiatrien Vest, Gl. Landevej 49, Herning, Denmark, Tel: 7847-4660, E-mail: antonio.drago76@gmail.com
Int J Psychol Psychoanal, IJPP-ii-013, (Volume 2, Issue 1), Review Article
Received: March x, 2016: Accepted: June 22, 2016: Published: June 24, 2016
Citation: Drago A, Marogna C, Søgaard HJ (2016) A Review of Characteristics and Treatments of the Avoidant Personality Disorder. Could the DBT be an Pick? Int J Psychol Psychoanal 2:013.
Copyright: © 2016 Drago A, et al. This is an open-access article distributed under the terms of the Artistic Eatables Attribution License, which permits unrestricted apply, distribution, and reproduction in whatsoever medium, provided the original author and source are credited.

Abstract

Avoidant personality disorder (APD) is a frequent disorder whose prevalence has been reported to be equally high as 10% in mental clinic outpatients. There is an open debate on whether APD is to be considered a unlike disorder compared to social phobia (SP), or they are dissimilar quantitative manifestations of the same pathologic procedure. Treatment for APD is mainly based on prove gathered for SP or SP in co-morbidity with APD. Suggested pharmacological treatment of APD is SSRIs or SNRIs. At that place is no articulate cut evidence in literature that 1 course of psychotherapy is superior to another for the treatment of APD, also because of the paucity of published evidence. It has been recently suggested that a modified form of the dialectical behavioral therapy (DBT) could be used for the treatment of APD, together with other diagnoses that share over-control as a psychological mechanism. The present contribution reviews the published evidence on APD and describes the main bug that are nowadays debated most this disorder.

Keywords

Avoidant personality disorder, Psychotherapy, Pharmacotherapy, Social angst

Highlights

• Avoidant personality disorder is frequent in the general population.

• It is debated whether avoidant personality disorder is a separated disorder from social angst.

• Treatment for avoidant personality disorder mainly overlaps with the handling of social angst.

• Avoidant personality disorder is best pharmacologically treated by SSRI or SNRI.

• An accommodation of the dialectical behavioral therapy may stand for an selection for the psychotherapeutic treatment of avoidant personality disorder.

Introduction

Avoidant personality disorder (APD) has just recently entered the group of personality disorders, together with the publication of the DSM-Iii in the eighties of the final century. The presence of both social phobia (SP) and AVP in the DSM-Three is proof that anxiety tin be viewed in two different ways. The first one dating back to the kickoff of the last century [ane] states that anxiety is to be considered a symptom disorder as the other phobias, the other i states that at to the lowest degree some forms of anxiety are to be interpreted in a broader constellation of trait symptoms that are strictly associated with the psychological makeup of a person [2]. The article that promoted the distinction between APD and SP was published past Turner and colleagues in 1986 [3] but the difference betwixt the two disorders could have been a result of the utilize of the diagnostic criteria for the APD during the study. These criteria were stringed and requested all 5 APD symptoms to be nowadays in gild to diagnose a APD. The same criteria changed in the revision of the DSM-III and were shifted to a polythetic approach, allowing less severe patients to exist diagnosed with APD. The inclusion of less severe patients with a diagnosis of APD may be held accountable for the possible overlap between SP and AVP equally reported in unlike studies. The evidence related to this consequence is detailed in the torso of the present contribution. A long debate in literature still doubts its etiological independence from feet disorders, and the current pharmacological prescribing guidelines for APD are in line with such statement, as discussed in the present contribution. Despite being a chronic disorder that is frequent in the general population and among patients that suffer from mental disorders - lifetime prevalence is estimated effectually 1.5% in the general population and xv.2% among psychiatric patients -, APD has not been ane of the chief focus in enquiry in the final decades (Figure one and Figure 2).

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Figure one: Number of published papers on PumMed for personality disorders organized by clusters.
The well-nigh function of manufactures published on PubMed so far (December 2015) are about cluster B disorders. Keys for designing the plot were for instance: "Avoidant personality disorder" NOT ("Dependent personality disorder" OR "Obsessive-compulsive personality disorder") NOT ("Paranoid personality disorder" OR "Schizoid personality disorder" OR "Schizotypal personality disorder") Not ("Antisocial personality disorder" OR "Borderline personality disorder" OR "Histrionic personality disorder" OR "Narcissistic personality disorder") and related permutations. View Effigy 1

.

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Figure 2: Number of published articles on PubMed for personality disorder organized per kind.
The Hating and Borderline disorders attracted much attention by Authors during the last xxx years. Keys for designing the plot were for example: "Avoidant personality disorder" Not ("Dependent personality disorder" OR "Obsessive-compulsive personality disorder") NOT ("Paranoid personality disorder" OR "Schizoid personality disorder" OR "Schizotypal personality disorder") NOT ("Antisocial personality disorder" OR "Borderline personality disorder" OR "Histrionic personality disorder" OR "Narcissistic personality disorder") and related permutations. View Figure 2

.

The aim of the present contribution is to identify the main characteristics (part 1 of the nowadays contribution) and the possible pharmacological and non pharmacological treatments for APD (part ii of the present contribution). Other relevant issues related to the disorder, such as its possible genetic underpinnings, the clarification of the psychological theories that tried to explain the disorder (zipper and cognitive for case), together with the possible complications of the disorder, are non discussed hither, only can be institute in a recently published review on the topic [4]. The concluding role of the present contribution is dedicated to the possible application of a modified version of the Dialectical Beliefs Therapy (DPT) to the handling of the APD.

Methods

Pumbed and PsycInfo were searched for references using the following keywords in permutation: "avoidant AND personality AND treatment"; "avoidant AND (psychodynamic OR cerebral)"; "avoidant AND Dialectical Behavior Therapy". Bibliographies of the single published articles were manually searched in social club to consummate the collection of the data. Previous reviews and research articles were identified. Inclusion criteria for enrollment in the nowadays work were: 1) shall exist written in English; 2) shall be a review or a instance-control research article; three) should focus on treatment of avoidant personality disorder or on epidemiological or etiological investigation; 4) should not be case reports; five) should not exist protocol description. A special precaution was dedicated to the identification of manufactures reporting negative association findings in society to limit a possible publication bias.

Function 1

Definition of APD

Persons with avoidant (anxious) personality disorder (APD) show a pattern of behavior that originates early on during adolescence and is characterized by extreme shyness, feelings of inadequacy and sensitivity to rejection. This cluster of feelings arise from a constitutive and persistent idea of inferiority to other people together with the expectation to be poorly judged by others. Symptoms are expected to be farthermost in the presence of APD. A diagnosis is to made with extreme cautiousness in children and adolescents, and only when information technology causes severe social impairment and personal suffering. Supplementary file 1 presents the DSM-V diagnostic criteria for APD. Supplementary file 2 shows the ICD -x diagnostic criteria for the same mental disorder. The pattern of behavior during APD must exist stable in time and response to a variety of personal and social situations must be inflexible and determining an extreme deviation from what is considered the mean behavior in the cultural groundwork of the person affected past the disorder. It is reported that patients diagnosed with APD tended to be shy during their infancy but their shyness and car-inhibition of social contacts do not ameliorate as the fourth dimension passes by, until it becomes so astringent as to betoken a diagnosis of APD. Symptoms related to APD ameliorate afterward in adult life [5], simply the disorder seems to be stable over fourth dimension with 56% of patients diagnosed with APD remaining at or above threshold later two years from the initial interview [half-dozen].

Before DSM

The first personality disorder to exist classified according to the contemporary scientific perspective was the antisocial personality disorder, which was first defined every bit a status of "moral insanity" past Prichard in 1837 [7]. The first systematic clarification of personality disorders equally separated from the other psychiatric disorders, and not merely precursors of them, was done by Schneider in 1923 [8]. This first classification did not include APD. Instead, the affection-less personality (antisocial and schizoid personality disorders), the labile personality (borderline personality disorder), the anankastic personality (obsessive compulsive personality disorder) and the depressive personality (depressive personality disorder) were described.

APD in DSM

The first DSM (DSM-I) appeared in 1952. In this beginning classification of the DSM, personality disorders were qualified past an absence of subjective anxiety, and petty or no sense of distress, with mental or emotional distress being much less of import compared to the patters of action and behavior. The DMS-Ii appeared in 1968 with a broader and more sophisticated nomenclature of personality disorders, which did nevertheless not include APD. In the DSM-3 (1980) personality disorders were classified in the Centrality II, which was a relevant option, considering clinicians were then invited to consider a diagnosis for personality disorder for all of their patients. The DSM-III too brought another relevant alter in the nomenclature of personality disorders, providing a number of symptoms for each disorder. Of note, the set of criteria was polythetic, none of them was necessary or sufficient alone to have a diagnosis of a specific personality disorder. It was with the DSM-3 that the APD was classified within cluster C together with the obsessive compulsive, dependent and passive-aggressive. The DSM-IIIR was published in 1987 and brought no substantial changes to the diagnosis of APD, nor did the DSM-Iv in 1994 or more recently, in 2013, the DSM-five. The diagnostic criteria of APD in DSM-5 are reported in supplementary file 1. Of note, two different approaches are implemented in the DSM-five in order to diagnose a personality disorder. The first one is categorical in nature and represents the continuation of the DSM-IV, this is embedded in the section II of the DSM-5. On the other mitt, the section 3 of the DSM-five implements an alternative model for the conceptualization and the diagnosis of personality disorders, which is dimensional in nature. Following this latter system a number of impaired core performance would be common for all personality disorders, including core impairments in cocky (identity and cocky-directedness) and interpersonal functioning (empathy and intimacy). This impairments represent the cluster A of this classification. In the cluster B are reported the variants that may differentiate the personality disorders equally they are classified in the section 2. A list of maladaptive domains that are composed and differentiated in 25 facets are described in different groups including: negative emotionality, detachment, antagonism, disinhibition, psychoticism and a general severity indicator. The APD was the merely one of the personality disorders to exist incremented by not-specific traits [9], and boosted diagnostic data for this specific personality disorder accept been proposed to be depressivity and perseveration [10].

The APD was i of the last of personality disorders to be included in the historical nomenclature of these disorders. This historical aspect is besides consistent with the difficulties to tell apart APD from other anxiety disorders that are classified in Centrality I of the DSM.

Prevalence of ADP

APD is i of the nearly frequent personality disorders [xi,12]. Lifetime prevalence is estimated around one.5% in the general population and 15.2% amongst psychiatric patients [13]. The 12 month prevalence of APD was 2% in the UCLA family study [14], a population sample in the Norway reported a lifetime prevalence of 2.seven% [xv], which was consistent with what reported in an American epidemiological sample, 2.4% [16]. A Swedish investigation reported a much higher prevalence of the disorder, 6.half-dozen%, under a self-administered questionnaire [17]. The National Survey of Mental Health and Wellbeing (NSMHWB) reported an estimated 12 month prevalence of 1.5% for APD [xviii] in a Australian sample from the general population. Table 1 reports a detail of some selected evidence on this topic.

Table one: Research prove on the treatment of APD. Prevalence and comorbidity. View Tabular array 1

Co-morbidity of ADP

APD segregates with Axis I and Centrality II psychiatric disorders. The rate of co-morbidity is particularly high for social phobia (SP), to the point that question arose as to whether APD and SP should be treated as ii different diseases, or they should exist better described as a continuum. Lampe and colleagues [19] reported that 26% of patients with SP have also APD, and 37.3% of patients with APD as well have SP. The presence of both disorders was associated with a higher degree of distress, also when controlling for low and substance corruption, which would advise the presence of two different diseases rather than an overlapping in diagnosis [16]. In the NESARC report 39.5% of patients with APD also had SP, the charge per unit of co-morbidity was every bit high equally 32.5% in a female twin study [xv] and the rate of co-morbidity was estimated to exist higher in a large outpatient sample in Kingdom of norway, where 48% of patients with APD also had SP [20]. Other reports testify a somehow lower level of co-morbidity betwixt SP and APD [21]. A high degree of co-morbidity between APD and depressive disorder has as well been reported [22], and ane third of patients with anxiety disorders is expected to take APD according to some reports [21]. Stuart and colleagues found out that APD'due south traits are common among all the three clusters of personality disorders co-ordinate to the DMS-IIIR [23], and Zimmerman and colleagues reported that while the prevalence of APD in their sample was as high as xiv.seven%, the prevalence of the APD together with other personality disorders was every bit high every bit 58.7% and it was one of the beginning-ranked personality disorder in co-morbidity with other personality disorders in the sample under analysis (OR = 12.3 in combination with schizoid personality disorder and OR = four in combination with paranoid personality disorder p < 0.01) [23]. Table one reports a detail of some selected reports on this topic.

Are SP and APD different disorders?

Evidence for APD and SP being two different diseases: The question whether SP and APD should be treated as unmarried entities or every bit a continuum is an ongoing open argue in literature. The current classifications (DSM, ICD), describe two different entities and some lines of evidence are consequent with this. For case, the prevalence of SP is as high as thirteen% in some reports [24], the 12 month prevalence in the United States would be as loftier as 7% [25-27]. This prevalence is college than what reported for APD, and a deviation prevalence would point to two different disorders. Moreover, the degree of overlap betwixt the two disorders might be related to the used diagnostic criteria, as discussed in [xx]. A big longitudinal investigation involving 1,471 twin subjects indicated that qualitative and non only quantitative differences would exist betwixt SP and APD [28]. An interesting report was conducted by Huppert and colleagues to test - among others - that SP and APD answer different to the treatment, which would suggest the presence of different etiological processes at the footing of the disorders. As a result, it was reported that there was overall no difference in response between the groups, but the presence of APD was associated with a faster comeback during the initial phase of the treatment, an result that was interpreted in the light of the more severe symptomatology that affects patients with both disorders, which would issue in a faster amelioration of symptoms during the first phases of the treatment [29].

Evidence for APD and SP existence a unmarried disease: Tillfors and colleagues reported that SP and APD are best described as a continuum when they are analyzed in the context of the familiar aggregation of social phobia [17]. The same conclusion was drawn by Ralevski and colleagues who investigated a sample of 224 patients with APD and 101 patients with both diagnoses [30]. Co-ordinate to this conceptualization, APD would be a more than severe variant of SP [31,32]. A large recent study on SP and APD involving 16,399 individuals with SP and ii,673 individuals with APD suggests that the two disorders are etiologically related and may stand for unlike results of a mutual biological procedure [33]. Finally, Hummelen and colleagues underlined that the diagnosis of APD or SP can be the issue of a different understanding of social phobia. In the first case, SP would be the issue of a specific psychological makeup, which together with a constellation of other characteristics or symptoms, would increment the run a risk for a diagnosis of APD. On the other instance, SP tin exist considered every bit ane of the different phobias and tin be conceptualized as an anxiety disorder [20]. This differentiation is consistent with the initial conceptualization of the two disorders that was included in the DSM-Three: SP as an excessive fright of performing in social situations, and APD as a problem of forming shut interpersonal relationships due the feelings described before in this text. In their extensive review on this topic, Alden and colleagues suggested that a categorical arroyo would exist non as efficacious as a dimensional approach in club to understand and meliorate diagnose persons who experience angst in association with social situations [21]. In particular, the dimensions of social anxiety, avoidance of novel situations, depressed mood and nature of interpersonal difficulty would provide useful in the understanding of the relationship between APD and SP.

Part 2

Pharmacological treatment: Background

There is no currently drug treatment canonical for the handling of personality disorders. Pharmacological handling is nevertheless used in practice "off-label" [11,34]. The apply of pharmacological treatment in personality disorders is in near cases aimed to stabilize patients' symptoms in order to facilitate psychosocial interventions and psychotherapy [11]. The same concept can be applied to APD. The pharmacological treatment of APD every bit the master diagnosis and with no other co-morbidities has non been extensively investigated in literature. The current understanding on the pharmacological handling of APD is based on the supposition that there exists a significant overlap betwixt APD and SP in terms of response to pharmacological treatments, and at that place is no show that the ii disorders differ in terms of biological correlates [11].

Pharmacological handling of APD

Guidelines for the biological handling of personality disorders accept been published by the Globe Federation of Societies of Biological Psychiatry (WFSBP) IN 2007 [xi]. Authors suggest that SSRIs and Venlafaxin may exist effective in addressing the biological treatment of APD. Reversible inhibitors of mono-amino-oxydase (moclobemide and brofaromine) are to exist considered 2d line treatments for APD/SP. Irreversible mono-amino-oxydase inhibitor (phenelzine) should not used because of the risk of serious side furnishings [34]. To the best of our noesis, at that place is no published prove on the efficacy of the employ of second generation anti-psychotics or mood stabilizers for the treatment of APD.

Psychological treatments: Background

Anxiety is conceptualized in dissimilar means in psychodynamic and cognitive oriented treatments. Feet as a symptom is of prime relevance in the theory of psychodynamics. Starting with the work of Freud in the first of the final century, feet was regarded as a result of the threads associated with impulses [35,36]. The object relation theory and self psychology [37-39] showed that the origin of conflict may exist the fear of annihilation, persecution, separation, fusion or disintegration. When anxiety is over-represented, it becomes itself a symptom. The psychodynamic theories of anxiety exercise not generically dismiss the biological aspects of the disease [forty,41]. A disturbed cocky-concept would be a central component of anxiety co-ordinate to Hoffman [42], which would outcome in a disturbed cocky-esteem and unrealistic expectations about the reaction of others in social surroundings. Gabbard [forty] suggested that anxiety is the result of the want to exist at the eye of the others' attention, associated with the unrealistic expectation, that the others will requite a negative evaluation. The anticipated negative response from disapproving parental figures might be involved in the process. Patients that express anxiety in social environments take been found to have an insecure attachment style [43], and separation anxiety would exist fundamental in anxiety disorders as a reaction to the fearfulness of losing an important bond with the caregiver, when moving towards independence.

In line with these studies, Ainsworth [44] showed that the mothers of these children express a rejection of the normal children's needs of dependency, and Grossmann and Grossmann [45] observed a mother struggling to take and comprise the sadness of children that later adult APD. On the opposite side of Winnicott [46] reports the aforementioned demand of defensive distancing in children who have parents too intrusive, pushy or too involved, every bit a risk factor for a later on development of APD. In the evaluation of Mahler relational models [47] it gives much importance to interpersonal transactions that include the responses, reactions and coping styles of the parents in the separation -individuation process. The answers they provide to the growth of the kid go are crucial for the overcoming of separation anxiety aroused by the awareness of separation between self and the agent of the maternal care.

This given, subjects with pathologic anxiety would avoid situations in which such a case-scenario may happen. Personality development unfolds in a play between contact and separation, the recognition and affirmation of the Self. With the purpose of reconciling these opposing tendencies the Benjamin [48] defines the "paradox of needs recognition" as the need for acceptance that leads to the dependence on the other. The resolution of the paradox lies in the same paradox, which must be maintained as a abiding tension between the recognition and affidavit of self, a dynamic that involves the recognition of the need for interdependence. Bornstein [49] describes a continuum that passes from dependence maladaptive (submission), to interdependence (relatedness) and arrives to the unyielding independence (detachment devoid of relationships). Some individuals placed extreme of unyielding independence accept loftier dependency needs that keep out of consciousness by means of denial and reaction formation. There is therefore a dependent personality disorder disguised every bit pseudo-independence. Counter-dependent individuals would disapprove the expression of needs and look down the signs of emotional vulnerability in themselves and in others, with a prevailing affection of shame, and the demand to compensate with some hugger-mugger area of habit, equally a substance or ideology. Avoidant personality can then be seen every bit a relational perversion in which the natural need of addiction is turned upside downwardly in a defensive counter-dependence where the prevailing intra-psychic conflict seems to be Finding versus Dependence. The pathological dependent relationships bargain with the inability to reconcile the antithetical needs merely necessary and, in particular, with the denial of the demand for recognition and distortion of this need in the domain [50]. By this fashion the avoidance of social situations becomes a mode to dominate the feet as a alert sign of involvement and therefore of dependence.

According to the psychodynamic model of the avoidant personality, avoidant patterns are characterized by accounted safe in staying away from sure dangers and how to deal with anxiety is tying it to specific situations and feared to be avoided. Psychological functioning is therefore organized around themes that include the anaclitic-avoidant issues. Phobic individuals may be agape of their suffering and the sensation of their ain emotional states. Like the patients with the alexithymic avoidant need to be accompanied to recognize, proper noun and express their emotions.

These would be the reasons why subjects with feet would actively prefer to avert social contacts, or develop feet when they are in social environments. Psychodynamic interventions were deemed to be "possibly efficacious" when treating a fan of psychiatric disorders [51] which can be considered as a result of the scattered published prove available for psychodynamic oriented psychotherapies in specific disorders. This is because efficacious treatments are defined later on being reported as efficacious in at least ii different RCTs [51]. Psychodynamic treatments are not targeted on precise diagnoses by their nature, every bit they focus on specific underlying mechanisms including affect regulation, mentalization, internalized object relations and insecure attachment, rather than on specific symptoms. This approach may represent a limitation when it comes to gauge the efficacy of a psychodynamic treatment alone or in comparison with other kinds of treatments. For this reason, unifying psychodynamics treatments for assessing the efficacy of the psychodynamic treatment of anxiety disorders, including the APD, have been proposed [52].

Psychological treatment options for APD. Psychological treatments: Testify on APD as a primary diagnosis

Alden and colleagues [53] reported on ten-week cognitive behavioral group therapy for 76 patients with APD and reported on the efficacy of the handling equally a whole, but it was also not evident that whatsoever specific aspect of the treatment was superior to any other, and treatment provided meliorate results that non-treatment for subjects with APD. The treatment was focused on a specific techniques such as the establishing of specific goals within the groups, group give-and-take, therapist involvement and support, clarification of problems and goals. Specific aspects were: one) identifying the fears underlying the avoidant pattern, two) increasing awareness and 3) shifting focus from fright to action. Graduated exposure and training of interpersonal skills were likewise office of the treatment together with focus on intimate relationships. Emmelkamp and colleagues [54] reported on a sample of pure APD patients, randomized to a twenty weeks psychodynamic or cerebral treatment. As a result, patients in the cognitive group (n = 21) reported significant better results compared to patients in the psychodynamic group (n = 23) and the benefits of both treatments were maintained after vi months. Both treatments were better than the command grouping. Rees and colleagues [55] recently reported on the efficacy of a brief cognitive therapy, merely the sample was equanimous of only two subjects, so the conclusions of efficacy driven by the Authors cannot be generalizable.

Psychological treatment options for APD. Psychological treatments: Testify on APD not every bit a primary diagnosis

Few RCTs on psychodynamic oriented psychotherapies for anxiety disorders take been published so far. A selection of published prove is reported in table 2. Overall, the available prove suggests that psychodynamically oriented psychotherapies are effective in treating anxiety disorders equally a whole, just a large-scale RCT comparing psychodynamic and cerebral psychotherapies for social anxiety reported that rates for response and remission were 52% and 26% for psychodynamic interventions and 60% and 36% for cognitive psychological interventions [56]. An ultra-brief psychodynamic treatment was investigated past Beretta and colleagues [57] on a sample of 27 patients with cluster C personality disorder out of seventy patients included in the analysis. The intervention was a formalized four-time session psychodynamic oriented intervention. 33% of patients showed an amelioration of clinical symptomatology at the end of intervention and it is reported that results were maintained subsequently 6 months from the treatment. Winston and colleagues [58] investigated a sample of 81 patients with personality disorders who were randomized to a psychodynamic oriented cursory psychotherapy (40 weeks) and to another form of psychotherapy. Authors reported efficacy of both interventions compared to the waiting listing, and no difference in efficacy was detected betwixt the two different forms of psychotherapy. Simply a part of the initial sample was diagnosed with APD, so these results are to be generalized to APD with cautiousness. Another report conducted past Svartberg and colleagues in 2004 [59] found that both the psychodynamic and the cognitive psychotherapies were constructive in treating a sample of 50 subjects with cluster C personality disorder. Results were maintained after 2 years follow-upward. In particular, after 2 years follow-up, 54% of the patients treated with psychodynamic psychological handling and 42% of patients treated with cognitive psychological treatment had recovered. APD was present in 64% of patients treated with the brusk dynamic psychotherapy and 60% of patients treated with the cerebral behavior handling. Once more, results are not generalizable to APD, due to the heterogeneity of diagnosis in the samples, but they are still suggestive that both the psychodynamic and the cognitive treatments are effective in treating APD. A mixture of dynamic and cognitive treatments were used in a interesting survey in Norway which took reward of "The Norwegian Network of Psychotherapeutic Day Hospitals", which envisages group therapies for patients with personality disorders and other psychiatric diagnoses [lx]. The sample included a prepare of personality disorders (northward = 1010) among other psychiatric diagnoses (n tot = 1234), and APD was nowadays as the main diagnosis in 253 subjects. Treatment was effective for all patients, including APD, merely patients without personality disorder experienced better outcomes compared with patients with both Axis I and Axis Ii diagnoses. Nevertheless, after i year follow-up, both groups showed similar developments. APD showed results that did not exceed those plant for the other personality disorders. These studies are of relevance in addressing the efficacy of psychodynamic or cognitive treatments for patients with personality disorder and APD in particular. Nevertheless, the number of patients involved in each study and the substantial lack of studies that focused on the APD mandate cautiousness in interpreting the information. APD has a strong overlap of symptoms with feet disorders as coded in the Axis I of the DSM, and the high co-morbidity between anxiety disorders and APD may suggest that results from the studies that implicated psychotherapies in the treatment of anxiety disorder may provide results that are useful for the investigation of the upshot of the same therapeutic strategies in APD patients. Classically, cerebral based interventions for feet disorders focus on the detection of internal and external anxiety cues, and the evolution of strategies to deal with the somatic and psychological symptoms [61-64]. In particular, it is relevant in the arroyo used by cognitive interventions to: ane) recognize feet; ii) clarify thoughts and cognitions that are associated with the symptom; 3) develop coping skills and 4) evaluate outcome. Behavioral methods include modelling, exposure to the event that is cause of feet for the subject, role playing and relaxation. Self control strategies such as self-ascertainment, self-modification, self-evaluation and self-advantage are central in the cognitive approach to mental disorders [65]. A number of meta-analyses showed the superiority of CBT to treatment every bit usual for the treatment of anxiety disorders (encounter for instance the recent work by Watss and colleagues, [66] or [67] or [68]), also when administered online [69]. Brown and colleagues reported that as much as 47% of patients could no longer been diagnosed with APD after a cerebral intervention. However, the superiority of the CBT over the psychodynamic oriented treatments has been recently questioned [68,70] and more than studies are needed to address this point.

Tabular array 2: Psychotherapeutic interventions in APD. View Table 2

Focus on Dialectical Behavioral Therapy (DBT)

DBT is a CBT that specifically addresses skills deficits and issues related to motivation for change. DBT is mainly used for the treatment of borderline personality disorder. DBT was beginning employed in 1991 by Linehan and colleagues [71] for the treatment of chronic suicide beliefs in patients with borderline personality disorder. It is a complex therapy, ordinarily delivered over one yr, which uses CBT, mindfulness, credence and dialectics in gild to trigger amelioration in the direction of emotions and behaviors. The efficacy of DBT has been proved for the treatment of borderline personality disorder [72], merely results of DBT are amend compared to other forms of psychotherapy when para-suicide beliefs is concerned. This treatment is thought to be effective through the regulation of emotions, whose dysregulation is considered to be one of the most relevant characteristics of borderline personality (meet [73,74] for a review). Interestingly though, Davenport and colleagues [75] reported that DBT was able to ameliorate consciousnesses and agreeableness, but had poor consequence on neuroticism. Neuroticism indicates a number of personality traits that encompass negative feelings such as envy, fright, anxiety, jealousy and loneliness [76]. It appears that these traits are not changed after DBT, but an increased consciousness about them and the evolution of skills to control their effects towards the inner balance of emotions may provide useful in limiting their bear on towards mood, impulse and behavior. The core areas in which DBT is expected to assistance patients with borderline disorder are: 1) attentional control; 2) emotion regulation; 3) skills for interpersonal communication and iv) distress tolerance skills [77], the desired therapeutic effect is idea to exist obtained through "a balanced synthesis of both credence and change" [78] and the discussion dialectic stands for the effort of synthesize opposites in dialectic philosophy. In the example of borderline patients, opposites to be integrated may well exist represented by conflicting emotions and acute changes in the emotional state. Opposites in the case of APD may be represented by the desire of being together with the other persons, and the acute fear to exist unsuccessful in doing that. DBT includes weekly sessions with the therapist, grouping therapies in which skills for interpersonal communication and distress tolerance are empowered and the possibility to give phone calls to private therapists in case of acute distressing situations. DBT was also employed for the treatment of eating disorders. The ii disorders, borderline personality disorder and eating disorder, concur in about 34% of individuals [79]. Mutual to the 2 disorders, a set up of behavior is used to accomplish command over emotions [fourscore], and invalidating environment is idea to be primal in the evolution of the borderline personality disorder, and invalidation may result in the families of patients with eating disorders, due to the role played by trunk's weight in western societies. These aspects and the frequent co-morbidity provided the rational for trying the DBT in patients with eating disorders. Overall, DBT is considered effective against eating disorders [81], even though the settings have been often modified in order to meet the specific needs of the treated population. Those modifications included: additional groups, removal of individual sessions, inclusion of family sessions, or added investigator-created modules focused on eating, nutrition, or body paradigm. The introduction of new strategies within the DBT, such as the contingency management has too been proposed for the handling of eating disorders with DBT [82]. Contingency management is defined as the notion that the consequences of a beliefs influences the odds, that that behavior is acted once more. Information technology is a classical aspect of behavioral treatments and may involve reinforcement, punishment, extinction and other behavioral techniques. It is important to notation, that the furnishings of DBT in eating disorders where often compared with the waiting list of patients, so it is now not possible to address the question whether DBT is better than other forms of treatment for eating disorders. Van Dijk and colleagues recently demonstrated that DBT is effective in the handling of adults with bipolar disorder, showing that depressive symptoms, acute interventions later 6 months from the intervention and a decreased number of drops-out resulted from the application of DBT in bipolar disorder [83]. DBT was also applied to a limited number of young patients with bipolar disease (n = 14), with positive results in offshoot with pharmacological treatments of patients. As expected, DBT was particularly efficacious in decreasing suicide ideation together with depressive symptoms in the group of patients [84]. Feldman and colleagues provided evidence that DBT may exist useful in the handling of resistant depression, with a particular focus on the relation between emotional processing and depressive symptom: the interaction of the two dimensions resulted in decreased depressive symptoms in patients in handling with DBT, and increased depressive symptoms in patients in the waiting list [85]. Consistently, DBT showed promising results in the treatment of depressed older adults [86,87]. This terminal finding is of particular relevance, because psychotherapies are mostly offered to immature individuals, on the assumption that they would be constructive within persons that will develop themselves to a swell extent in the future. Thus, age limits and severity of symptoms should not discourage the utilize of psychotherapy in borderline patients, and also in other groups of patients [85,87,88]. DBT has been adapted for the handling of other personality disorders. A group in England developed a cognitive therapy called transmission-assisted cognitive-behavioral therapy (MACT), focused on the analysis of maladaptive behaviors, the providing of techniques for handling negative emotions and tolerance to distress. A beginning airplane pilot report in 1999 provided promising results for this technique [89]. Feigenbaum applied DBT to a group of patients with personality disorders, without focus on a specific personality disorder [ninety]. The total number of patients included in the DBT group was 25, 11 patients completed the study for DBT and 17 and 14 patients were reachable for follow up for DBT and the handling as usual respectively. seven out of them had antisocial personality disorder, 9 out of them had avoidant personality disorder. The other personality disorders were less represented. No sensitivity analysis was performed, this also due to the small number of patients involved in the assay. The final finding, was that DBT was as effective equally the handling as usual in decreasing clinical risk and distress. Due to the small number of patients included in the grouping, it is possible to assume that the study had non enough power to observe a difference between the ii treatments. DBT was successfully used for the treatment of antisocial personality disorder [91]. An interesting arroyo was recently used past Lynch and colleagues [92] in the definition of a Radically Open-Dialectical Behavior Therapy (RO-DBT), which is not focused on a single diagnosis, but rather tries at address a number of disorders that are hard to treat for the shared characteristic of maladaptive over-control. Examples might be anorexia, chronic low - or at least some of the patients with chronic low - and obsessive compulsive personality disorder. A core concept of RO-DBT is that the emotional loneliness that patients feel is a consequence to a depression openness and social signaling deficits which are in directly associated with the problem of over-control. This might be well the outcome with APD, during which patients controls the adventure of the anticipated frustrating social relationships, by systematically avoiding them.

Tin DTB be adapted to APD?

To the best of our knowledge, the applicability of DBT to APD has not been investigated past independent groups in literature, so that the question addressed in the title of this paragraph cannot be properly answered. In order to adjust DBT to the treatment of other mental disorders, it is of import that iii theoretical indicate are discussed and proved true during the phases of adaptation or later. This statement finds its rational in the concept that DBT was developed and proved efficacious to subtract self-harm behavior and emotional dysregulation in patients with borderline personality [77]. When transferred to the treatment of another diagnosis, three assumptions are made: 1) the diagnosis that should be treated with DBT includes emotional dysregulation, two) DBT treatment is efficacious in treating emotional dysregulation in the diagnosis nether assay and 3) the effect of DBT is to reduce the symptoms that characterize the diagnosis under analysis. When applying these points, it is possible to say that patients with APD diagnosis exercise not show the aforementioned amount of emotional dysregulation as patients with borderline personality disorder. This simple clinical observation would dampen the application of DBT to APD. It has been all the same reasoned that DBT may be used for the treatment of emotional symptoms that are found in the opposite farthermost compared to the emotions that narrate deadline patients. These symptoms may be related to the concept of over-control. A number of patients that are diagnosed with anorexia, obsessive compulsive disorder or chronic low may display a pattern of thoughts or beliefs that are characterized past over-control [93-95]. Following this prove, Lynch and colleagues proposed a modified DBT for the treatment of disorders that share over-control as a determining psychological gene associated with the severity of the symptomatology [96]. These disorders include paranoid personality disorder (PPD), obsessive-compulsive personality disorder (OCPD), avoidant personality disorder (APD), non-BPD anorexia-nervosa, and chronic low. The original goal of DBT is to reduce impulses and highly variable and massive emotions that characterize the disorder. The accommodation of DBT that promotes openness and flexibility while reducing rigid thinking. A minimum length of 28 weeks is suggested past Authors, together with a skills preparation group. Skills are the same suggested past Linehan [77], with the exception of distress tolerance skills and with a new skill targeted on the credence and forgiveness.

Determination

APD is a frequent personality disorder characterized past farthermost shyness and isolation associated with the fearful expectation of existence negatively judged by the others, together with the actual desire of being in social situations. Characteristics of the disorder are the high co-morbidity with feet disorders every bit described in the Axis I of the DSM. Subjects with APD are highly socially incapacitated and blank a quantity of personal suffering which may be poorly recognized past others due to the tendency of these subjects to isolate themselves. Inquiry on the treatment of APD is still in its infancy, and there is a lack of prove based treatments for this kind of disorder [54,97]. Pharmacological treatment of APD is mainly based on the employ of SSRI and SNRI, even though this assumption is mostly based on the efficacy of these drugs on anxiety disorders coded in the Centrality I. Psychological interventions may as well be used for the handling of APD but there is not enough evidence in literature to sustain that a treatment is preferable to another i. A limited number of published show investigated the furnishings of cerebral psychotherapy on samples of APD patients, where APD was the chief diagnosis [53-55]. Results signal into the direction of the efficacy of the treatment compared to non treatment at all. Due the loftier efficacy of DBT in the treatment of borderline personality disorder, it has been suggested that the same technique, together with some specific modifications that more precisely tailor the cadre of APD, may be used. This modified DBT treatment has been proposed by Lynch and colleagues [96], and it is based on the supposition that over-control may be a relevant strategy that subjects with APD developed in gild to balance their inner psychological balance. Further research is mandatory to investigate the efficacy of this modified DBT model on APD.

Conflicts of Interest

Authors declare no conflict of involvement.

Part of Funding Source

The present work was not funded.

Supplementary File ane

DSM V criteria for avoidant personality disorder.

A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning past early machismo and present in a diverseness of contexts, as indicated by 4 (or more than) of the following:
1. Avoids occupational activities that involve meaning interpersonal contact because of fears of criticism, disapproval, or rejection.
2. Is unwilling to go involved with people unless certain of beingness liked.
3. Shows restraint within intimate relationships considering of the fear of being shamed or ridiculed.
4. Is preoccupied with being criticized or rejected in social situations.
5. Is inhibited in new interpersonal situations considering of feelings of inadequacy.
6. Views cocky every bit socially inept, personally unappealing, or inferior to others.
7. Is unusually reluctant to take personal risks or to appoint in whatsoever new activities because they may show embarrassing.

Supplementary File two

ICD - 10 criteria for avoidant personality disorder.
A. The general criteria for personality disorder are met.
B. At least four of the following are met:
ane. Persistent and pervasive feelings of tension and apprehension.
ii. Belief that oneself is socially inept, personally unappealing or inferior to others.
3. Excessive preoccupation about being criticized or rejected in social situations.
4. Unwillingness to get involved with people unless certain og beingness liked.
5. Restrictions in lifestyle because of demand of security.
half-dozen. Avoidance of social or occupational activities that involved significant interpersonal contact, because of fear of criticism, disapproval or rejections.

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