This said, Benjamin notes that especially troublesome problems of differential diagnosis arise when social phobia generalizes.13 This was the case for a socially phobic adolescent afraid of going to school because of a painful startle reaction to the loud school bell. This child soon also became so fearful of all street noise that she was unable to leave the house at all without her mother. Eventually, as an adult, she stayed home with her mother all day, every day, her phobia having spread so that the only meaningful relationships she could have, besides the one with her mother, were the close relationships she developed with her cats.
A careful developmental history can help distinguish patients with generalized social phobia from patients with AvPD. As children, people who go on to develop AvPD are more likely to pull back from others than are people who go on to develop social phobia. The latter as children tend to have normal relationships both at home and outside of the home, for example, they play well with others and their peers aren’t focused on picking on them. But they are more likely to suffer from childhood phobias such as agoraphobia—limiting their movement more than they limit their potential ability to relate.
Therapeutically speaking, social phobics respond to treatment that emphasizes developing cognitive insight into the symptom (“you fear public speaking because you feel that if you make a minor mistake then all will be lost”); informal or formal behavior therapy that offers the patient tasks of graded difficulty geared to overcoming the specific behavioral inhibition(s) involved; and possible pharmacotherapy to reduce anxiety. In contrast, patients with AvPD tend to do best developing insight into the full nature and meaning of the interactive problems that keep them from becoming, and remaining, intimate with significant others. Conversely, it is just common sense that cognitive-behavioral techniques, particularly techniques of graded exposure, will not likely be as helpful for treating an ongoing and generalized fear of closeness, intimacy, and commitment as they might be for treating an encapsulated fear of public speaking. While a patient afraid of public speaking can ask himself or herself, in a reassuring manner, “What is the worst that can happen?” then expose and habituate himself or herself to the anxiety associated with the feared situation until he or she can perform comfortably and safely, shy avoidants afraid of intimacy and commitment have difficulty using exposure methods therapeutically because getting over their “dating anxiety” would require trial intimacies and commitments, which, if at all possible, would be selfish and cruel to others in the extreme.
Invoking an ad hominem argument I base on my own personal observation, I feel that behavioral therapists’ vested interests (in doing behavioral therapy) tend to tempt them to obscure the diagnostic difference between AvPD and social phobia so that they can treat all concerned the same way, that is, behaviorally. In contrast, psychodynamically oriented therapists’ vested interests (in doing insight-oriented, psychodynamically oriented psychotherapy) tempt them to emphasize the differences between a phobic symptom and a personality problem such as AvPD so that they can reserve cognitive-behavioral interventions for the social phobic and use strictly psychodynamically oriented psychotherapy for the patient with AvPD.
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don’t have time to meet people. One man placed a personal ad on the Internet and then, making it look as if his work left him no time for fun, arranged to always be too busy to respond to any takers.
I’m not ready; young men like me should play the field a while longer. Some field players are profitably studying the terrain, but many are commitment phobics excusing their inability to play, while others are neophiliacs abandoning old lamps for new because being thrill
DIFFERENTIATING AVPD FROM BORDERLINE PERSONALITY DISORDER
The full, fundamental and frequent alternate merging and emerging of borderline personality disorder has to be differentiated from Types Ila and Ilb avoidant partial, infrequent, and mostly defensive shifting between closeness and distancing. As the DSM-IV says, the borderline process is notable for a “pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.” 14 This ambivalence about forming and maintaining interpersonal relationships leads borderlines to alternately love too well and hate too intensely: to develop close ties then drop people impulsively, seducing then abandoning them suddenly and without provocation or warning. We see a pattern where the borderline closes in and distances (merges and emerges) along the lines of Freud’s quaint simile of porcupines, who, seeking warmth, approach each other because they are cold but who then, pricking each other with their quills, move farther apart to relieve the discomfort, only to feel cold again and move closer together once more. One day, borderline individuals feel lonely, hunger for contact, and call and come over constantly, and the next day, they remain aloof, refusing invitations to visit or be visited, not even returning phone calls. Now they are relentless seekers of love and affection, and now, however much they unconsciously fear loneliness and abandonment, they disrupt potentially workable relationships offered or already in progress. When they are involved in relationships, they dream of how wonderful it was to be alone and grouse vocally that relationships invade their space and feel too close for comfort. Then, when they arrange to be alone, they dream of how wonderful it was to be involved in relationships and complain that others do not get close enough quickly enough. But when they are once again involved in relationships, they provoke others to provide the match that lights the fuse that explodes the tumescent bomb of their long-simmering avoidant fantasy—so that they can blow up over things that people concerned with relationship maintenance would at least try to forgive and forget: not replacing ice cubes after using them; not covering the unused portion of the cat food thus allowing the food to dry out; or putting feet up on the sofa, even when the sofa is old and the feet are clean.
Too, unlike the avoidant, who distances as a way to handle fear associated with being close, the borderline merges and emerges as a way to gratify need. Borderlines first merge after overestimating others as all good, assigning individuals the qualities of savior wise and true, and actively courting them out of a need to relieve intense loneliness and achieve a sense of comfort and satiation. Only then, brought up short in disappointment, they come to underestimate others as all bad and actively dump them out of a need for vengeance, seeing only others’ real, perceived, or delusionally perceived minor flaws so that they can award them the qualities of villain, fool, and cheat, in turn so that they can now avoid embracing them and instead consign them to complete oblivion.
Some Case Examples
My team and I saw a patient without an appointment as an emergency for a two-hour visit, then offered follow-up care the next day with both me and a psychologist. At first, the patient felt, “You people are wonderful—look how much time you spend with me.” Then, in short order, she changed her mind to say, “You people are dreadful— you are trying to overwhelm me, get too close, and press me to open up and tell you my problems before I am ready. Besides, you are only doing this for the money.”