Avoidant personality disorder — structured clinical viva

This is a longitudinal pattern consistent with avoidant personality disorder, not a moral failure or simple shyness. Confirm general PD criteria and ≥4 of 7 DSM features (occupational avoidance for fear of criticism, need for certainty of being liked, intimate restraint for fear of shame, preoccupation with rejection, inhibition from inadequacy, self as inept/inferior, risk avoidance). Assess concurrent social anxiety disorder — dual diagnosis is often correct on the continuum rather than forced either/or.[1][5]

Differentials. Schizoid PD (ask desire for connection — she likely wants relationships), ASD (developmental history), major depression as amplifier, dependent PD, body dysmorphic disorder if appearance-focused. Late-onset organic change is unlikely if lifelong.[1]

Treatment. First-line is structured psychotherapy: CBT with graded exposure, dropping safety behaviours, cognitive restructuring of inadequacy beliefs. Schema therapy is a named option when global self-concept dominates — Bamelis multicentre RCT supports schema therapy for personality disorders including Cluster C-relevant samples. Do not “force group” without alliance; paced exposure prevents confirmatory humiliation. Medication does not cure personality; SSRIs treat comorbid SAD/depression — e.g. sertraline 50 mg orally daily with titration and early activation review. Network meta-analysis supports psychological and pharmacological interventions for adult social anxiety continuum care.[2][3][4][5]

Risk. Rejection and evaluation crises elevate depression and suicide risk; plan for means safety and rapid access. Avoid chronic benzodiazepines as the only social strategy.[1]