- 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.
I love her!
You should check our what Dr. Ramani has to say on narcissists!
She's my favourite doctor out there!
This comment intends to assure you to look into the work (videos) of that woman!
There's a lot to hikikomori concerning the war between empaths and narcissists
Find your place in the war!
Look at your dragon in the eye and pull the sword!