7 Signs of Avoidant Personality Disorder

Summary

In this insightful episode, Dr. Ramani demystifies the diagnosis of avoidant personality disorder (APD), outlining the multifaceted process involving clinical interviews and life area assessments. She clarifies that APD is not a straightforward diagnosis but a nuanced pattern of fear, rejection, and social inhibition, often confused with social anxiety or depression. Dr. Ramani emphasizes the importance of a thorough, evolving diagnostic journey, cautioning against quick diagnoses or one-size-fits-all solutions. The episode provides a deeper understanding of APD and the significance of a collaborative therapeutic relationship.

Takeaways

• 🧐 Diagnosing avoidant personality disorder (APD) is a nuanced process requiring multiple interactions to understand the pervasiveness of the condition in various life areas.
• 🕵️‍♂️ The diagnostic journey for APD involves a series of clinical interviews to assess the individual's social, familial, and occupational functioning.
• 🔍 Individuals with APD often seek treatment due to loneliness and frustration from an inability to connect with others, which can be mistaken for social anxiety or depression.
• 🤔 The distinction between social anxiety and APD lies in the core fears—social anxiety is about immediate physiological reactions, while APD is rooted in a deep-seated fear of rejection and criticism.
• 📝 The criteria for APD diagnosis according to the DSM include a pervasive pattern of social inhibition, fear of rejection, and social and occupational impairment.
• 🚫 People with APD avoid activities involving interpersonal interaction due to a fear of making mistakes and being criticized.
• 🤝 They are hesitant to engage in relationships unless they are certain of being accepted, which can lead to vulnerability and potential manipulation.
• 💭 Individuals with APD may hold back in intimate relationships due to a fear of being shamed or ridiculed by their partner.
• 🤷‍♂️ They often feel socially inept and less skilled than others, which inhibits their willingness to take social risks and miss out on opportunities.
• 🎤 APD is characterized by a reluctance to take risks or try new things in social settings for fear of embarrassment, which can limit life experiences.
• ⚠️ Quick diagnoses and promises of instant cures should be met with skepticism, as the understanding of APD is an evolving and complex process.

Q & A

What is the general process for diagnosing a personality disorder according to Dr. Ramani?

The diagnosis of a personality disorder, including avoidant personality disorder, is not a quick process. It often requires multiple interactions with a client to understand their experiences in various life areas such as friendships, family, romantic relationships, and work or school. Personality disorders are pervasive and can affect many areas of a person's life.

Why might someone with avoidant personality disorder initially come into treatment?

Individuals with avoidant personality disorder may seek treatment due to feelings of loneliness and frustration from not being able to connect with others. These feelings can be the driving force that brings them into therapy.

How does Dr. Ramani differentiate between social anxiety and avoidant personality disorder during the diagnostic process?

Dr. Ramani explains that while social anxiety is more about the physiological reactions and fear of 'screwing up' at the moment, avoidant personality disorder involves a deeper sense of fear of rejection, criticism, and hypersensitivity. It's a nuanced distinction that may take time to discern through ongoing therapy sessions.

What are some common reasons people seek mental health treatment according to the script?

People often seek mental health treatment due to depression, relationship problems, dating issues, or conflicts within family dynamics. These issues can act as catalysts for individuals to seek help and enter therapy.

How does Dr. Ramani approach the use of psychological testing in the diagnostic process?

Psychological testing can provide insight into patterns of behavior and thought that are indicative of certain disorders. While it can offer a faster way to an end goal, Dr. Ramani emphasizes that spending time with the client to understand them holistically is still crucial.

What are the DSM criteria for avoidant personality disorder as outlined by Dr. Ramani?

The DSM criteria for avoidant personality disorder include a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to rejection and criticism. This can manifest in avoidance of occupational activities with interpersonal interaction, reluctance to get involved with others unless acceptance is guaranteed, restraint within intimate relationships, preoccupation with criticism, inhibition in new interpersonal situations, self-judgment as socially inept, and reluctance to take social risks.

Why might someone with avoidant personality disorder avoid promotions or career advancement?

People with avoidant personality disorder may avoid promotions or career advancement because these situations often involve increased interpersonal interaction, which they fear due to a fear of making mistakes, looking foolish, or facing criticism.

How does the fear of rejection manifest in avoidant personality disorder according to the script?

The fear of rejection in avoidant personality disorder can manifest as an avoidance of getting involved with others unless there is certainty of acceptance. This fear can also lead to restraint in intimate relationships, where individuals may hold back from sharing vulnerabilities or personal thoughts and feelings.

What are some red flags to watch out for when seeking a mental health professional, as suggested by Dr. Ramani?

Dr. Ramani suggests being wary of professionals who are quick to diagnose or promise quick fixes. The diagnostic process for personality disorders is nuanced and typically requires time and multiple interactions to accurately assess.

Why does Dr. Ramani prefer not to use diagnostic labels with her clients?

Dr. Ramani prefers not to use diagnostic labels with her clients because she believes it's more meaningful to focus on the specific fears and experiences causing distress. She aims to have conversations about the 'ingredients' of their struggles rather than applying a label.

At what age do personality disorders typically begin to be diagnosed, according to Dr. Ramani's experience?

Dr. Ramani suggests that personality disorders are not typically diagnosed before the age of 18, as the personality is still developing through adolescence. She prefers to wait until individuals are 21 to 25 years old, as this allows the personality to take shape before a label is applied.

What type of questions would Dr. Ramani ask a client she suspects might have avoidant personality disorder?

Dr. Ramani would ask about the client's social relationships, including friends, dating life, and family relationships. She would explore the quality and duration of these relationships, as well as the client's feelings and experiences within them, to identify consistent patterns of fear and avoidance.

What is a common misdiagnosis for avoidant personality disorder, as mentioned in the script?

A common misdiagnosis for avoidant personality disorder is social anxiety disorder or other anxiety disorders. Additionally, due to the social isolation and feelings of sadness associated with avoidant personality disorder, depression might also be an initial misdiagnosis.

Outlines

00:00

🤔 The Complexity of Diagnosing Avoidant Personality Disorder

Dr. Ramani discusses the intricate process of diagnosing avoidant personality disorder (APD), emphasizing that it's not a straightforward task. It involves multiple interactions to understand the individual's life areas, including friendships, family, and work, due to the pervasive nature of personality disorders. The initial presentation of APD might be loneliness and frustration in connecting with others. The diagnostic journey includes ruling out other conditions like social anxiety or depression and identifying the fear of rejection and hypersensitivity unique to APD. Dr. Ramani shares her experience of reevaluating initial impressions of social anxiety to eventually diagnose APD after observing consistent patterns over time.

05:02

🔍 Criteria and Risks Associated with Avoidant Personality Disorder

This paragraph delves into the specific criteria outlined in the DSM for diagnosing avoidant personality disorder, characterized by a pervasive pattern of social inhibition, feelings of inadequacy, and fear of rejection. The summary highlights the avoidance of occupational activities involving interpersonal interaction, reluctance to engage with others without assurance of acceptance, and restraint within intimate relationships due to fear of shame or ridicule. It also addresses the risks of falling into manipulative or abusive situations due to vulnerability and the challenges of self-expression in social settings. The paragraph concludes with the dangers of self-judgment and the reluctance to take social risks, which can lead to missed opportunities for personal and professional growth.

10:05

⚠️ Red Flags in the Diagnostic Process for Personality Disorders

Dr. Ramani warns against the red flags in the diagnostic process, particularly the quick diagnosis driven by external pressures such as insurance requirements. She stresses that psychiatric diagnosis is an art that unfolds over time, unlike medical conditions with definitive tests. The paragraph emphasizes the importance of a nuanced and evolving diagnostic approach, cautioning against professionals who offer quick fixes or overly simplistic solutions. Dr. Ramani also discusses her preference for discussing symptoms and patterns rather than labels, aiming for a more meaningful conversation with clients about their experiences and distress.

15:05

👶 Age Considerations and Typical Diagnostic Path for APD

The discussion turns to the typical age at which avoidant personality disorder might be diagnosed, with Dr. Ramani suggesting that it's uncommon to issue such diagnoses before the age of 18 due to the ongoing development of personality during adolescence. She advocates for observing personality development up to 21 to 25 years of age before labeling. The paragraph also touches on the early signs of APD patterns emerging in late adolescence and early adulthood, while acknowledging that individuals may have struggled with social fears and inhibitions throughout their childhood.

20:06

💡 Therapeutic Approach to Identifying Avoidant Personality Disorder

In this paragraph, Dr. Ramani outlines the therapeutic approach to identifying APD, starting with questions about an individual's social relationships, dating life, and family dynamics. She explains the process of identifying consistent patterns of fear and inadequacy across all relationship types. The summary describes how recognizing these patterns can lead to a deeper exploration of the individual's history, including potential experiences of shame or trauma, and how this understanding can be liberating by providing a broader context for their struggles.

📋 Common Misdiagnoses for Avoidant Personality Disorder

The final paragraph addresses common misdiagnoses for avoidant personality disorder, such as social anxiety disorder and depression. It highlights how individuals with APD might initially be perceived as socially unskilled or inferior due to depression, leading to an incorrect early diagnosis. The summary underscores the importance of accurate diagnosis to ensure appropriate treatment and support for individuals struggling with APD.

Keywords

💡Avoidant Personality Disorder (APD)

Avoidant Personality Disorder is a mental health condition characterized by a pervasive pattern of social inhibition, feelings of inadequacy, and extreme sensitivity to rejection. In the video, Dr. Ramani discusses the diagnostic process for APD, highlighting its complexity and the need for multiple interactions to understand the individual's life experiences fully.

💡Diagnostic Process

The diagnostic process refers to the method used by clinicians to identify and confirm a mental health condition. In the context of the video, Dr. Ramani emphasizes that diagnosing APD is not straightforward and requires a series of clinical interviews to gather comprehensive information about the individual's social and occupational functioning.

💡Clinical Interviews

Clinical interviews are a fundamental part of the diagnostic process where a mental health professional engages in a conversation with a patient to understand their experiences, symptoms, and history. Dr. Ramani mentions the importance of these interviews in determining the pervasiveness of APD and its impact on various areas of the patient's life.

💡Social Anxiety

Social anxiety is an intense fear of social situations due to a fear of being judged, embarrassed, or rejected. In the video, Dr. Ramani differentiates between social anxiety and APD, noting that while both involve social fears, APD is more about pervasive feelings of inadequacy and rejection sensitivity.

💡Depression

Depression is a common mental health disorder characterized by persistent feelings of sadness, loss of interest, and a lack of energy. In the script, Dr. Ramani points out that depression is often a reason people seek mental health treatment and can be associated with APD due to the social isolation experienced by those with the disorder.

💡Psychological Testing

Psychological testing involves administering a series of tests to assess an individual's cognitive, emotional, and behavioral patterns. Dr. Ramani mentions that these tests can provide insight into the patterns associated with APD and may be used as part of the diagnostic process to understand the individual's mental health more holistically.

💡Fear of Rejection

Fear of rejection is a central theme in the video, particularly in the context of APD. It refers to the intense apprehension of being criticized, disapproved of, or turned down by others. Dr. Ramani explains that this fear is so pervasive in individuals with APD that it significantly impacts their social and occupational activities.

💡Social Inhibition

Social inhibition, as discussed in the video, is the reluctance or avoidance of social interactions due to feelings of self-consciousness, inadequacy, or fear of judgment. It is a key feature of APD and is deeply intertwined with the individual's fear of rejection and social inadequacy.

💡Occupational Impairment

Occupational impairment refers to the negative impact on an individual's work or career due to a mental health condition. In the video, Dr. Ramani describes how individuals with APD may avoid promotions or interpersonal interactions at work due to their fear of making mistakes and being criticized, leading to potential stagnation in their careers.

💡Cognitive Distortion

Cognitive distortion refers to irrational or exaggerated thought patterns that can perpetuate emotional distress. In the context of APD, Dr. Ramani mentions that individuals may have a cognitive distortion of viewing themselves as socially inept, which reinforces their avoidance behaviors and social inhibition.

💡Risk Aversion

Risk aversion is the tendency to avoid situations involving uncertainty or potential negative outcomes. Dr. Ramani explains that individuals with APD are highly risk-averse, especially when it comes to social situations where they might embarrass themselves, leading them to miss out on opportunities for growth and social connection.

Highlights

Diagnosing avoidant personality disorder requires multiple interactions to understand the pervasive impact on various life areas.

Avoidant personality disorder is characterized by a pervasive pattern of fear of rejection and social inadequacy.

Individuals with avoidant personality disorder may avoid occupational activities due to fear of criticism and mistakes.

They are often unwilling to get involved with others unless they are certain of being accepted, leading to limited social interactions.

People with avoidant personality disorder may restrain from sharing vulnerabilities in intimate relationships due to fear of shaming.

They often hold back from expressing opinions in social situations due to a preoccupation with being criticized.

Feelings of inadequacy inhibit new interpersonal relationships and can lead to self-deprecation in professional settings.

Avoidant personality disorder is associated with self-judgment and a belief of being socially inept compared to others.

Individuals with this disorder are reluctant to take risks or try new things in social settings for fear of embarrassment.

Diagnosis should not be rushed and requires a nuanced understanding of the individual's experiences over time.

Quick diagnoses or cure-alls should be approached with skepticism as the diagnostic process is complex and evolving.

Therapists should avoid fixating on labels and instead focus on the underlying fears and patterns causing distress.

Avoidant personality disorder is often under-researched compared to other personality disorders, but is gaining more attention.

Diagnoses of personality disorders are typically not issued before the age of 18 due to the ongoing development of personality.

Therapists use a combination of clinical interviews and psychological testing to identify patterns and diagnose avoidant personality disorder.

Misdiagnosis of avoidant personality disorder can occur, commonly being mistaken for social anxiety disorder or depression.

Therapeutic conversations should focus on identifying patterns and understanding the client's life experiences holistically.

Avoidant personality disorder's onset is typically seen in late adolescence or early adulthood, but its roots may be traced back to childhood.

Transcripts

- Understanding the diagnostic process

for a personality disorder is difficult,

but Dr. Ramani makes it simple.

In this episode, she explains how the path to a diagnosis

should and should not look

and walks through the seven criteria used

to diagnose avoidant personality disorder.

All right, Dr. Ramani,

what goes into diagnosing somebody

with avoidant personality disorder?

- You know, Kyle, as with all personality disorders,

it's not just sort of like a quick and easy

kind of a process.

Many times when we're,

when we come to the diagnosis of a personality disorder,

it can require multiple interactions with a client

to hear about how they're doing in various areas

of their life,

with their friendships, in their family,

with a partner, at work or at school,

because personality disorders tend to be pervasive.

So, if this is just somebody

who doesn't wanna do a sales talk,

but they're doing well in those other areas.

It takes time to get all that information.

So, at the core of it, in order to figure this out,

we need a series of clinical interviews,

or at least to start treatment with someone.

If a person with avoidant personality disorder

came into treatment, they may very well come into treatment

because they feel lonely and they feel frustrated,

and not being able to connect to other people,

that might be what brings them in.

So, when they're brought in

with that kind of a presenting issue,

we're gonna think about a lot of things.

Is this person socially anxious?

Is this person depressed?

You know, what's going on here?

And then we'll dig deeper.

And once we see the pervasiveness of it,

it might take us even a few weeks,

maybe even a few months to land on the summit squarely.

We'll also look at, for example,

how do they perceive how other people view them?

Is this more about being anxious

or is this really about feeling inadequate

and that people will reject them?

People who are socially anxious

are just more reacting to the physiological reactions

they're having at that time.

And yeah, they do worry about,

you know, screwing up, if you will,

but for the person who is experiencing

avoidant personality disorder, it really is,

it's the fear of rejection,

the fear of criticism, the hypersensitivity.

The themes are a little bit different

so it's a really nuanced kind of a path.

And I have to tell you,

I've worked with clients for maybe the first six weeks.

I thought, he's socially anxious.

And about week eight or nine, I'm like,

no, this might actually be more pervasive than that.

And it'll show me how much more severe and consistent it is.

And then I might do a little bit more work,

once I realize it's avoidant personality

on sort of unscrambling those fears

and focusing on it more as a pervasive pattern

than as an anxiety disorder.

- I would imagine that most people come in for depression.

- It's, depression is probably

one of the primary leading causes of why people

ever get into mental health treatment.

But I have to tell you,

there's also a lot of stuff of life that get people in,

relationship problems, dating problems,

but a lot of it's relationship problems.

And that's a lot of what brings people

over the threshold of my office,

problems in a marriage, problems with a parent,

problems with an adult child, something like that,

and that we can break it down from there.

So, sometimes people will even come in

with an entirely different kind of an issue,

and then it will end up coming in a back door on this one.

So, it really takes a lot of interviewing, time.

Sometimes people do psychological testing or assessment

and they'll give them a series of tests,

and those tests will give insight into these patterns.

And that's almost like a faster way to that end goal,

but no matter what, you still need to spend time

with a client to understand them wholistically.

- So, what are, what's the criteria and the DSM

for avoidant personality disorder?

- So again, it's this pervasive pattern

of sort of a fear of rejection and social inadequacy,

characterized by sort of being socially inhibited.

The first, and so much so,

that it creates a sense of social

and occupational impairment,

that it gets in the way of work,

it gets in the way of life.

So, the first criteria is that these are people

who avoid occupational activities

that have a lot of interpersonal interaction

because of they're afraid of basically screwing up

and looking foolish or making a mistake or criticism.

And so, you can see how that could hold someone back

in a job.

It's a pretty rare job where you never have to have contact

with other people.

And in some industries it's a requirement.

So, they'll go out of their way to avoid that,

including doing things like avoiding promotions,

avoiding transfers, avoiding sort of forward motion

in their career, which can hurt them in many ways.

Lower income, you know, growth in their job, job security,

but they'll go out of their way to avoid that.

The second is that they're not willing to get involved

with other people, unless they're sure

that there'll be accepted.

Now, when you think about that,

when do we ever have that kind of assurance?

There's almost something child-like about that, right?

And what happens then

is because you rarely get that reassurance,

they're not very likely to enter

into close personal relationships.

And this is where I also say there's a danger to that,

because sometimes it's easy for someone to manipulate them

or trick them or toy with them

because they can find someone who may really accept them

because they're trying to get something from them,

money or something else like that.

And so, in those cases, the person almost feels like

it's a guarantee, come into our cult place

and you can come be with us and we all love you.

You can see with that vulnerability

is everyone's liking them, no matter what.

You can see how they that's really a setup

for falling into some dangerous

and expensive situations of people

who actually don't have their best interests at heart

and could be very emotionally manipulative or abusive, okay?

People with this pattern also show restraint or hold back

within intimate relationships

because they're afraid they'll be shamed by their partner

or ridiculed by their partner.

So, what that means is they're reluctant

to share about themselves,

they're reluctant to share their vulnerabilities,

their intimate thoughts or feelings,

because they're afraid that, for example,

let's say they shared a romantic or sexual fantasy

that their partner would make fun of them

or actually downright shame them.

And so, that fear means that

they almost feel like they're,

and some people could interpret it

as almost like they're being aloof, they're being cold,

they're being distant, they're being overly shy,

but they're doing that because of their fear.

- Yes.

- Of being shamed.

The fourth is continuing with that preoccupation.

They're preoccupied of being criticized

in social situations.

So, as a result, for example,

they won't offer up an opinion, right?

They won't share,

even if they have an opinion about something,

they'll hold back on that,

because that, as you can imagine,

especially in this day and age of so much polarization,

that they'll be so afraid

that somebody would make fun of them

for having that opinion.

So, they'll show not only in an intimate relationship,

but any social situation that fear of being rejected

or criticized has them holding back,

sharing really anything that meaningful

for fear of that rejection.

The fifth criteria for this disorder

is that they feel inhibited,

when they're in a new interpersonal relationship

because they feel inadequate.

So, that could be a new friendship,

that could be a new colleague,

it could be a new partner.

But because they feel so inadequate, they feel less than,

they very much hold back or feel very, very awkward.

And they'll often sort of put down

what it is they do for a living.

I've worked with many clients,

like that have the most interesting jobs,

but sometimes they're sort of like,

they're quirky or they're off the grid

and they're almost ashamed of it.

So, they hold back,

like, I don't wanna tell anyone what I do for a living

'cause they're gonna make fun of me.

And if that happens, even once that can inhibit them

for many, many years after that.

So, that's always their fear.

So, they won't even go there.

And it's hard because you can't curate how the world

is gonna react to someone,

but because they feel so inadequate,

they, especially when they meet new people,

they really, really hold back.

Criterion six is that people

with avoidant personality disorder, they judge themselves.

They consider themselves to be socially inept

and less socially skilled than other people.

So, that's literally their identity when they go in.

So, like, oh, don't ask me

or don't have me talk to them.

I'm the wrong person.

They'll always assume everybody's more socially skilled.

In many ways, that's a cognitive distortion,

but it feels very, very real to them.

And what that means, then,

and once again, they're socially inhibited.

They take no risks.

They miss a lot of opportunities.

And because of that, it keeps reinforcing their identity

as being socially inept.

When, you know, they just that this is largely happening

up here for them

and they rarely get to sort of test themselves,

if you will, socially.

Finally, people with avoidant personality disorder

are very reluctant to take any kind of risk

to try something new,

especially, in front of other people,

because they're afraid they'll embarrass themselves.

So, let me tell you this right now,

a person with avoidant personality disorder

is never gonna do karaoke, okay?

That's the kind of thing.

They'll never be the person who jump up stage,

be a volunteer,

even step up at their brother's wedding.

That would be very upsetting

'cause it was so afraid of embarrassing themselves.

And again, there's even this interesting phenomenon,

where they're also afraid

that they're gonna embarrass other people,

who are being embarrassed by watching their awkwardness.

Does that make sense?

- It does.

- It's almost like this reciprocal sort of a thing.

So, because they'll never take any risks,

they miss a lot of life.

You know, like they won't,

they might be afraid, for example,

if there was like a cool pond to jump in off of a rock,

they won't do that

'cause they're afraid they'll jump in the wrong way.

They might be inhibited to try something on vacation

or try a new activity or anything like that.

So, they miss so much life

and they look at it almost like longingly,

but because they're so afraid of being embarrassed,

they won't try something new.

And they miss, they miss so much opportunity

for growth, curiosity, meeting new people,

advancement at work.

But that fear of embarrassment overrides

all of that sort of wanting to do it.

- The reason is important for viewers to know

what the criteria is and the DSM,

which is the manual professionals use to do these diagnoses

is because that is what you're going to keep

in the back of your mind,

as you are putting someone through this diagnostic process.

Now, as you put someone through this,

or when someone goes through this process

with a professional,

are there things that they should look out for

that would be a red flag of,

whoa, this professional is not doing their job,

whether that's quick to diagnose them with anything

or something like that?

- I think that quick to diagnose

is something I would struggle with.

And the problem is,

nowadays, there's sometimes a quick to diagnose

because various agencies expect a diagnosis.

- That's what people want.

- Does that makes sense?

They need it, they want it,

the insurance, call it what you will.

That's a problem.

And psychiatric diagnosis is not like diagnosing anemia,

where you stick a needle in someone's arm,

you take some blood, you run an assay

and you're like, oh, you've got anemia.

This is a very nuanced art.

And it's something that more so over time,

a person who initially may look socially anxious over time,

we learn has avoidant personality,

then we come to learn that they're drinking a lot

and they're drinking a lot to manage.

You know what I'm saying? - [Kyle] Yeah.

- And so, this it's like,

it's something that blossoms over time.

And I think there needs to be a real respect

for that process.

So, if somebody says,

I can take care of that for you in three sessions, you know.

And so, I think that the quick cure-alls,

that I have some magical way,

a magic bullet, a magic pill, if you will,

to make all of this go away,

I think people should be leery of that.

I wish we did.

I. - Me too.

- I absolutely wish there was some mantra

I could give somebody and say,

say this 10 times, and you are good to go.

- [Kyle] Yeah.

- It's not like that.

And while I've seen extraordinary growth

for many clients in therapy, not just with me,

but with many of my colleagues who are clinicians,

this is sometimes not only a slow, it can be a slow process,

but it's an arduous process.

I mean, it's a commitment on both sides

of the therapist and the client.

So, I think anyone who's like,

we can deal with this in just a few sessions.

I've got a magical manual that will make this go away,

a very quick diagnosis.

And more than anything,

because the way we come to diagnosis is an evolving process,

somebody who gets so stuck, like, no, you have this,

no, you have this,

as more information comes in about where a person's at,

that's also important too.

And I'm gonna be frank with you.

I don't talk with my clients, in terms of their diagnosis.

I don't like that.

I don't want it to be hi, Kyle, my, whatever you are,

my anxious person.

You know, we'll talk about it in general terms,

like I'd rather talk about avoidant personality disorder

and not use those three words.

I'd rather call it things like,

you know, your fear in social situations.

- [Kyle] I get that, I get that.

- And I keep coming back to that terminology.

To me, diagnoses are shorthand.

- I get that.

- And I like to talk with my clients

in terms of the ingredients,

because it's the ingredients that are causing them distress.

- Yes.

- And I think that's a much more meaningful conversation.

- Yes, I 100% I'm on board with that.

Has anyone ever come into your office

and said, hey, Dr. Ramani, thanks for seeing me.

I have avoidant personality?

So, nobody's even aware.

- Nobody's ever said that, no.

I've had people come into my office and say,

hi, I have narcissistic personality disorder

or hi, I have borderline personality disorder.

Maybe they've seen other clinicians,

but I've never in my career

had someone walk into my office

and say, this is what I have.

- Why?

- I think that, first of all, the name is strange, right?

You know, so they're thinking they're struggling with like,

they get really anxious around other people.

- Anxiety, yeah.

- So, they think of it as an anxiety disorder.

The idea of avoidance,

the name wouldn't even make sense to them.

And I think that a lot of times

these people have been branded

as socially awkward, ultra shy,

those kinds of words have been used.

So, they don't even think that this is

sort of more of a consistent diagnostic pattern.

You got to remember, this is one of those patterns

that's only recently getting

a little more research interest,

but it is not like patterns like borderline personality.

They've gotten tons and tons of research put on them,

mostly because it's a much more distressing disorder

for people experiencing it,

but avoidant personality is also very uncomfortable.

So, we're seeing more and more work on it for sure.

- What would you say in your experience is the typical age

someone gets diagnosed with APD?

- You know, I think, with all personality disorders

and I hold to this,

we do not really issue these diagnoses

much before the age of 18.

The personality still developing through adolescence.

And I'm a bigger fan of even holding off to 21 to 25,

because I think adolescents in our culture

is now going all the way up to 25, frankly.

And I don't even mean that tongue in cheek.

I mean, that's seriously.

- I get that.

- We call it transitional adulthood,

but it's just expanded adolescence.

So, I like to sort of see the personality sort of take shape

before we sort of toss a label on it.

But I think that we would start seeing these patterns onset

and late adolescence, early adulthood in any systematic way.

However, these are people who have struggled

with this pattern of fear, fear of rejection,

fear of inadequacy, feeling socially inhibited,

probably through their entire childhood.

- [Kyle] Right.

- So, it's not like they're fine socially

and then one day they hit, you know, 18

and all of a sudden they become,

you know, it becomes more difficult for them socially.

This pattern's been in there.

- Just for fun.

I come into your office and let's say,

it's been a few sessions.

You start to think that I might have APD.

What type of questions would I hear?

- Say, you know,

talk to me about how, talk to me about sort of your friends.

Tell me about the people you spend time with, okay?

Find out about their dating life

and dig deeper into their relationship.

How many relationships have they had?

How long have they lasted?

How did they meet?

What are their relationships like

within their family, their workplace.

So, I'd really do some digging around

how all of their social relationships feel.

And what I think would then start to emerge

is the same theme over and over again.

Yeah, I don't really have that many friends.

They might need even say, I've never had a relationship

or it's hard for me to get into a relationship.

I don't really like dating.

They may report intact familial relationships,

but I wouldn't be surprised if we found out

that their familial relationships

were also fraught with anxiety,

given the origins of this pattern.

But I would be looking to see if there's a consistency

around the fears, the fears of inadequacy,

all those fears, cutting across all relationships.

And once we got there, I would point that out.

- Yeah.

- It's not like I'm trying to do some sort of voodoo magic.

I'll say, do you see the consistency in this pattern?

And they'll say, yeah.

And I'm actually kind of aware of it.

I never thought of it that way.

Many times when we,

it's almost like taking all the stuff out of someone's house

and laying in a pattern.

Oh, I never knew I had 27 pairs of black shoes.

- That is a metaphor.

Yes, that is so it.

Oh my gosh.

That's my takeaway.

- [Dr. Ramani] Yeah.

- That's so big.

That that's big on a, on a,

even a broader conversation of mental health and therapy.

- Yeah, yeah.

- It's like going into your house and going,

I didn't know I had three can openers.

- Right, and we're unpacking it and laying it all out.

So, a good psychologist, a good therapist

lays out all the information.

And I actually draw out pictures for each of my clients

or diagrams that help me sort of see,

you know, patterns that I have,

like all these weird ways I do it.

It's really just for myself.

But once I start seeing a pattern,

then I go into the next session

and I sort of sniff around it.

And then I present, I say,

look at this, this is something I'm noticing.

How does that feel?

And they'll say, I don't agree with that.

And then I respect that because we're not,

I'm not gonna be right all the time.

I'd be lucky if I was right 75% of the time.

And then say, okay,

and then I'll work with them collaboratively.

But many times when they have 27 pairs of black shoes,

they'll say, shoot, I guess they were in,

all over the scattered all over the house.

And so, now that I'm seeing them here like this,

that's really what it becomes.

So, we look for the pattern and we see that universality.

And once they see that,

then we can really start,

that's when we then start going into childhood.

- [Kyle] Yeah.

- You know, what, what, where do you think this came from?

And that's where we'll often get into the ideas of shame,

how they were treated by peers.

They may have even had a very, very humiliating

first sexual experience.

For example, they may have been shamed

during a making out with a peer, early on,

or, you know, it could even be, in some cases,

that there's, there was sexual abuse

or unwanted sexual contact,

that could also push into this area of feeling fearful

around social interaction,

especially, if they were shamed for it,

which some children are.

And so, any of those things can contribute to this.

So, we go and listen, nobody's gonna,

very few clients, I should say, are gonna open with that.

That's something you respectfully work into.

And so, and then we get that

and we start helping them connect dots

'cause a lot of these people say, I'm just awkward.

And then we can say, I don't think you're just awkward.

Do you understand where this is coming from?

And it's no longer about a leaf and a tree.

You're showing them the roots, the trunk and the whole tree.

And they'll say.

- [Kyle] So good.

- Oh, now I see, thank you.

- [Kyle] Yes.

- And that's liberating for them

because they almost felt like they were being buffeted

on a sea.

Like, I'm just like this,

because there's something wrong with me.

- [Kyle] Yeah.

- And when they realize it's part of a much longer story,

a tree, if you will.

- Then they'll say, now I get this and we can start.

We can't un-ring the bell.

The past happened.

But they can think about it differently.

- Yeah, for our viewers

who this might be their first or second series

that they've watched from MedCircle,

that's such an important point,

for just to understand therapy, in general,

that it's not there to go,

now, we're gonna look at everything that's wrong with you.

so we can give you a label.

It's just understanding the truth about your life.

- Yeah.

- And the areas that you're really great in.

- Yes.

- And the areas that you can be better in

and just getting closer and closer

to that more optimal way of living.

- Right, right.

- What is a common misdiagnosis

that people with avoidant personality disorder will get?

- The most common, and I'm, maybe not misdiagnosis,

but like, it may not be the exact right diagnosis

is probably social anxiety disorder.

- [Kyle] Yeah, I figured.

- Or other anxiety disorders.

You may also see some misdiagnosis, if you will,

potentially of something like

depression because the person is struggling so much

with social isolation

and they feel sad about that social isolation.

And many people with depression

have inaccurate appraisals of themselves,

like they view themselves as socially unskilled

or socially inferior, that's the depression talking then.

So, that could be an early misdiagnosis as well.

- Yeah, all, all excellent points.

In our next episode, Dr. Ramani is going to give you

some quick, easy advice on what you can do

to help yourself find the right provider for you.

A critical piece of your mental health journey

coming up in our next episode.