Personality and Mental Health

6: 170–173 (2012)
Published online in Wiley Online Library
(wileyonlinelibrary.com) DOI 10.1002/pmh.1195

Commentary
A cognitive-behavioural perspective on
Personality disorders with over-regulation of
emotions and poor self-reflectivity: The case
of a man with avoidant and not-otherwise
specified personality disorder, social phobia
and dysthymia treated with Metacognitive
Interpersonal Therapy

RICKS WARREN, University of Michigan, Department of Psychiatry, Ann Arbor, MI 48109-2700, USA

Dimaggio, Attina, Popolo, Salvatore and Procacci and Fonagy (2000). Treatments should be well-
(2012) present a complex case of primarily structured,concentrate on enhancing compliance,
avoidant personality disorder (AvPD) with addi- have a clear focus, be theoretically coherent to both
tional dependent, depressive, paranoid and therapist and patient, be relatively long-term,
passive–aggressive personality traits, along with encourage a powerful attachment relationship
dysthymia, social phobia and erectile dysfunction. between therapist and patient and involve an active
As the authors note, there is no treatment manual therapist stance (Silk, 2010). At the end of 1 year of
for such complex cases, and Metacognitive treatment, the patient is reported to no longer suffer
Interpersonal Therapy (MIT) seems appropriate from any personality disorder, and improvement in
for the case presented. As Emmelkamp et al. social phobia and sexual problems also were
(2006) have noted, AvPD is highly prevalent in obtained. Given such a complex case with apparent
the community and is associated with even more failure to make clinically significant gains in 5 years
impairment than major depression. Of all the of previous CBT for social phobia, the potency of
personality disorders, it is the most persistent, and MIT is well supported.
it tends to worsen over time. Thus, effective In the remainder of this commentary, I will
interventions for AvPD are needed. suggest some details that would have been helpful
Metacognitive Interpersonal Therapy appears to have about this case and suggest that cognitive
to meet the criteria for effective treatment therapy/CBT for AvPD and social anxiety disorder
of personality disorders delineated by Bateman may be the preferred treatment. The authors report

Copyright © 2012 John Wiley & Sons, Ltd. 6: 170–173 (2012)

DOI: 10.1002/pmh
 A cognitive-behavioural perspective on personality disorders 171

that the patient previously had weekly CBT for emotions and interpersonal problems, regardless
5 years. It would be helpful to know what this CBT of diagnosis.
consisted of. Was it an empirically based, manual In a case report, Hofmann (2011) presented
driven CBT (e.g. Hope, Heimberg, Juster, & Turk, ‘the most severe case of social phobia/AvPD that
2000) that is the most extensively validated treat- was ever seen at the clinic’ (p.3) (Center for
ment for social phobia? Given Leonardo’s continu- Anxiety and Related Disorders). After 27 h of
ation to meet the criteria for AvPD, social phobia individual treatment, the patient no longer met
and other conditions, it appears unlikely. In fact, the criteria for any DSM-IV axis I or II disorder,
in one study, 47% of patients with generalized social and these gains were maintained at a 1-year
phobia with an additional diagnosis of AvPD no follow-up assessment. Further, in a randomized
longer meet the criteria for AvPD after 12 weekly controlled trial, Emmelkamp et al. (2006) com-
2.5-h group treatment sessions (Brown, Heimberg, pared 20 sessions of CBT vs. brief dynamic therapy
& Juster, 1995). Further, newer generation CBT for patients with AvPD and found CBT to be more
for social phobia treatments have been reported to effective at post-treatment. Gains were maintained
lead to even better outcomes (Hofmann, 2010; at 6-month follow-up, where 91% of patients no
Hofmann & Otto, 2008). Although Dimaggio longer met the criteria for AvPD. Although the
and colleagues utilized exposure techniques, ‘The treatment of Leonardo led to improvement with a
therapist therefore first asked Leonardo to not avoid year of therapy, the empirical evidence suggests that
meeting girls’ (p.10) and ‘This interweaving of CBT may be a more efficient intervention.
behavioural exposure and in-session reflection about As Dimaggio et al. note, ‘Leonardo always
mental states elicited by the encounter allowed believed he was unworthy and inept; he feared
Leonardo to recognize he felt a sense of self-efficacy criticism and was prone to feeling scorned’ (p.6).
during romantic rendezvous’ (p.12); it is not evident DSM-IV-TR criteria for AvPD include a prominent
that such techniques were used in a consistent, role for viewing ‘self as socially inept, personally
structured way. Systematic, hierarchical exposure to unappealing, or inferior to others’ and preoccupa-
a broad spectrum of anxiety-provoking and /or tion ‘with being criticized or rejected in social
avoided situations, a central element of CBT for situations’ (American Psychiatric Association,
AvPD and social phobia, may have provided greater 2000, p. 721). Converging research supports the
benefits and in a shorter duration of therapy. centrality of self-criticism and negative self-
Cognitive therapy has much to offer in the evaluation as potential core processes in AvPD
treatment of patients with more than one and social phobia. Cox, Walker, Enns and
personality disorder. Beck et al. (2004) list beliefs Karpinski (2002) in a CBT for generalized social
that are most strongly associated with specific phobia study found that changes in self-criticism
personality disorders. For example, patients with were significantly associated with outcome and
AvPD endorse such beliefs as, ‘I am socially concluded, ‘Our findings suggest that fear of
inept and socially undesirable in work or social negative evaluation may be linked to a more
situations’ and ‘Being exposed as inferior or pervasive disturbance about self-worth’ (p. 488).
inadequate will be intolerable’. Examples of beliefs Vogel, Ryum, Stiles and Svartberg (2009) recently
endorsed by patients with paranoid personality reported that increased self-acceptance predicted
disorder include, ‘If people act friendly, they may improvement in both cognitive-behavioural psy-
be trying to use or exploit me’ and ‘Other people chotherapy and short-term dynamic psychotherapy
will deliberately try to demean me’ (p. 61). Thus, of Cluster C personality disorders (Svartberg et al.
cognitive therapy provides a conceptual model 2005). Recently, Cox, Turnbull, Robinson, Grant
that guides the therapist to address the relevant and Stein (2011) reported that a follow-up of
maladaptive beliefs and resulting maladaptive nearly 300 patients (266) with AvPD from the

Copyright © 2012 John Wiley & Sons, Ltd. 6: 170–173 (2012)

DOI: 10.1002/pmh
172 Warren

Collaborative Longitudinal Personality Disorders In conclusion, MIT appears to meet the criteria
Study (McGlashan et al., 2005) ‘found that feelings for an effective treatment for personality disorders
of personal inadequacy at baseline was one of the (Bateman & Fonagy, 2000), and the case of
most stable criteria of AvPD, along with social Leonardo is illustrative of how this model concep-
ineptitude’ (p. 254). Cox et al. (2011) also suggest tualizes and treats a patient with multiple patholo-
that ‘the self-criticism construct could also be a gies. However, traditional cognitive therapy also
common psychological diathesis that underlies offers a coherent theoretical model and is the most
comorbid AvPD and GSAD’ (p.254). These evidence-based treatment. Cognitive therapy is
observations are consistent with the growing well suited for the incorporation of interventions
recognition of the pervasiveness of self-criticism that might best target core elements of AvPD,
throughout many forms of psychopathology social phobia and related emotional disturbances,
(Warren, 2011). The central role of self-criticism such as self-criticism. Recently, imagery-based
in both AvPD and social phobia suggest that interventions and methods for increasing self-
patients like Leonardo would benefit from treat- compassion are being incorporated into cognitive
ments that directly target this destructive process therapy and may hold promise in increasing
that maintains low self-esteem and shame. treatment effectiveness.
Currently, there is a burgeoning new literature
on the psychological benefits of self-compassion References
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ABPP, University of Michigan, Department of
Social and Personality Compass, 5(1), 1–12. Psychiatry, 4250 Plymouth Road, Rachel Upjohn
Shapira, L. B., & Mongrain, M. (2010). The benefits of self- Building, Ann Arbor, MI 48109–2700, USA. Email:
compassion and optimism exercises for individuals ricksw@umich.edu

Copyright © 2012 John Wiley & Sons, Ltd. 6: 170–173 (2012)

DOI: 10.1002/pmh