* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Rohrbauck MP 2012 - Adler Graduate School
Eating disorders and memory wikipedia , lookup
Claustrophobia wikipedia , lookup
Behavioral theories of depression wikipedia , lookup
Addictive personality wikipedia , lookup
Panic disorder wikipedia , lookup
Gender dysphoria in children wikipedia , lookup
Glossary of psychiatry wikipedia , lookup
Broken windows theory wikipedia , lookup
Selective mutism wikipedia , lookup
Munchausen by Internet wikipedia , lookup
Eating disorder wikipedia , lookup
Anxiety disorder wikipedia , lookup
Autism spectrum wikipedia , lookup
Conversion disorder wikipedia , lookup
Depersonalization disorder wikipedia , lookup
Sexual addiction wikipedia , lookup
Schizoaffective disorder wikipedia , lookup
Depression in childhood and adolescence wikipedia , lookup
Conduct disorder wikipedia , lookup
Generalized anxiety disorder wikipedia , lookup
Personality disorder wikipedia , lookup
Separation anxiety disorder wikipedia , lookup
Mental disorder wikipedia , lookup
Social anxiety disorder wikipedia , lookup
Antisocial personality disorder wikipedia , lookup
Spectrum disorder wikipedia , lookup
Child psychopathology wikipedia , lookup
Asperger syndrome wikipedia , lookup
Causes of mental disorders wikipedia , lookup
Dissociative identity disorder wikipedia , lookup
History of mental disorders wikipedia , lookup
Narcissistic personality disorder wikipedia , lookup
Diagnosis of Asperger syndrome wikipedia , lookup
Externalizing disorders wikipedia , lookup
Diagnostic and Statistical Manual of Mental Disorders wikipedia , lookup
Running head: CRITICAL FACTORS 1 Critical Factors Involved in a Move from Generalized Social Phobia to an Experience of Avoidant Personality Disorder from an Adlerian’s Perspective A Research Paper Presented to the Faculty of Adler Graduate School ___________________________ In Partial Fulfillment of the Requirements for Degree of Master of Arts in Adlerian Counseling and Psychotherapy ___________________________ By: Marcus Rohrbauck September 2012 CRITICAL FACTORS 2 Abstract The diagnostic criteria for Generalized Social Phobia and Avoidant Personality Disorder show considerable overlap between the two disorders, making accurate diagnosis difficult if not impossible. Since the publication of the DSM III there have been contradictory explanations of how to interpret the experience of these orders, whether they can coexist, or if they are distinct. Are these separate disorders or do they lay on a continuum? Due to the fact that the DSM is currently a categorical system of diagnosis clinicians must be able to provide clear distinctions between these disorders and up until this point it has failed to do so. Presupposing that these disorders do indeed lay on a continuum this review of the literature identifies the critical factors that lead an individual from an experience of Generalized Social Phobia to Avoidant Personality Disorder. Additionally, the American Psychiatric Association has outlined proposed revisions to the DSM-5 slated to be released in May of 2013. A shift towards the adoption of a hybrid categorical and dimensional model of personality disorder diagnosis has been suggested which may finally put an end to this debate. CRITICAL FACTORS 3 TABLE OF CONTENTS Abstract……………………………………………………………………………..2 Introduction……………………...………………………………………………....4 Psychopathology……………………………………………………………………7 Kurt Adler and Psychosis…………………………………………………………...11 Mental Illness and Choice…………………………………………………………..11 Historical Comparison of DSM Editions…………………………………………...16 Etiology of Anxiety………………..………………………………………………..17 Social Anxiety Disorder and DSM-IV-TR………………………………………….19 Avoidant Personality Disorder and DSM-IV-TR…………………………………...22 Sperry’s View of Personality Disorders……………………………………………..23 Distinction between Disorders………………………………………………………26 One Disorder on a Spectrum………………………………………………………...27 Critical Factors and Discussion……………………………………………………...29 Arguments for a Dimensional Shift in Diagnosis…………………………………....31 Personality Disorders and DSM-5…………………………………………………...36 Avoidant Personality Disorder and DSM-5………………………………………....37 Social Anxiety Disorder and DSM-5………………………………………………..39 Does DSM-5 End the Continuum Debate?.................................................................42 Clinical Implications…………………………………………………………………43 References……………………………………………………………………………48 Table 1, Characteristic differences between GSP and AVPD……………………….27 CRITICAL FACTORS 4 Critical Factors Involved in a Move from Generalized Social Phobia to an Experience of Avoidant Personality Disorder from an Adlerian’s Perspective According to the DSM-IV-TR “there appears to be a great deal of overlap between Avoidant Personality Disorder and Social Phobia, Generalized Type, so much so that they may be alternative conceptualizations of the same or similar disorders” (APA, 2000 p.720). Due to this overlap researchers such as Krueger & Eaton (2007), Ruscio, (2010) Turner, Beidel, & Townsley (1992), Sperry (2003), and many others have sought to determine the significant factors involved in sufficiently distinguishing these disorders. To elucidate which factors lead an individual from an experience of Generalized Social Phobia (GSP) to an experience of Avoidant Personality disorder (AVPD) many factors and perspectives must be considered. This review of the literature includes a historical comparison of the Diagnostic and Statistical Manual of Mental Disorders (DSM) from the third edition by the APA (1980) to the current fourth text revised (TR) by the APA (2000) version which will illustrate how the American Psychiatric Association (APA) over the past 32 years (since 1980) has sought and failed to resolve this debate. By first explaining the development of psychopathology from an Adlerian perspective based on the writings of Ansbacher & Ansbacher (1956), Griffith & Powers (2007), and Sisk (2010) the experiences of Generalized Social Phobia and Avoidant Personality Disorder will be presented. This dichotomy sets the stage for a discussion across a broad range of topics including: an Adlerian conceptualization of mental illness and how it relates to the DSM, whether mental illness is determined or a choice, and the problems with placing an arbitrary separation between Axis I and Axis II disorders. This final claim that the separation between Axis I and Axis II is arbitrary is supported by researchers Krueger & Eaton (2010) and their claims will be described in this analysis. The presentation of these topics will illustrate the need CRITICAL FACTORS 5 for a paradigm shift in mental health diagnosis by the inclusion of a dimensional model in both Axis I and Axis II diagnoses. Adlerian Etiology Before any discussion of the manifestation of any psychopathology can be undertaken the underlying root cause of all pathology must be acknowledged. According to Alfred Adler all psychopathology stems from feelings of inferiority and discouragement (Ansbacher & Ansbacher, 1956). Everyone is born into the world in a position of less than others for example; an infant is dependent upon its parents to meet its needs. A child, though more developed than an infant is still inferior in terms of their physicality to adults. They are short in stature and unable to reach things in high places, for example. Their brains are still developing and so they are also cognitively inferior to adults (Ansbacher & Ansbacher, 1956). Rudolph Dreikurs, a contemporary of Adler suggested that “children are expert observers but make many mistakes in interpreting what they observe” (Dreikurs & Soltz, 1964, p. 15). The consequence of this is that children make mistakes in their thinking and misinterpret the meaning of life experiences (Dreikurs & Soltz, 1964). Adler referred to this misinterpretation as a Mistaken Belief (Ansbacher & Ansbacher, 1956). If Mistaken Beliefs develop and are not corrected these beliefs may hinder the development of a socially interested individual. To understand the development of the personality or Lifestyle of an individual one must look at their family of origin. An individual’s family of origin is defined as anyone in that child’s immediate family; this would be traditionally defined as mother, father, and siblings (Ansbacher & Ansbacher, 1956). However, many families today are blended and so the definition can be broadened to whoever is relevant and important to the individual. The family is the first social system a child CRITICAL FACTORS 6 is placed in, followed by the school system, and later society as a whole. Within these social contexts a child develops beliefs about self, the world, the way it works and ought to work, what men are like, and what women are like (Ansbacher & Ansbacher, 1956). Adlerian theory also fits into a multicultural model because a child’s beliefs and Mistaken Beliefs can be identified no matter what the cultural background is. For example, a Hispanic adult (male) could describe an Early Recollection about his uncle. This early recollection would reflect the Hispanic man’s beliefs about self and the way the world works. These beliefs would also reflect the individual’s Hispanic culture and so regardless of the cultural differences between the client and their therapist the process of Individual (Adlerian) therapy would be the same. According to Ansbacher & Ansbacher (1956) the Lifestyle is set by the age of 5 or 6 based on the child’s experiences. Lifestyle refers to a person’s characteristic pattern of movement in the world. Life is about movement, purposive movement towards a goal. All behavior has a purpose and that purpose is strive towards what Adler described as the Final Fictional Goal. Ansbacher and Ansbacher explained the basic goals identified by Adler are a need for safety, belonging, and significance. Adler also described the tasks of life first described by Freud which are to love and to work; Adler emphasizing the significance of the social context added the task of friendship/community (Ansbacher & Ansbacher, 1956). To be psychologically healthy an individual must meet these basic needs and find a balance between the tasks of life. In addition to or perhaps most importantly Adler explained that they must do so in a socially interested manner (Ansbacher & Ansbacher, 1956). Social Interest is defined as an interest in the interests of others. According to Ansbacher & Ansbacher (1956) Adler defined Social Interest in the following quote: “to see with the eyes of another, to hear CRITICAL FACTORS 7 with the ears of another, and to feel with the heart of another” (p. 135). The degree to which Social Interest is present in an individual determines their level of mental health. Adler referred to Social Interest as the barometer of a child’s mental health (Ansbacher & Ansbacher, 1956). Adlerian therapy focuses on analyzing an individual’s family of origin including birth order, Early Recollections (which reflect Lifestyle convictions), and Dreams. The goal is to recognize a pattern of movement, not that past events necessarily caused present concerns but to recognize that there may be patterns of behavior possibly originating in childhood, that are affecting current functioning. Once these Mistaken Beliefs are identified they may then be corrected and replaced with more useful beliefs which are aligned with the Social Interest. Adlerian theory or Individual Psychology is a cognitive, psychodynamic, focusing on insight (not Freudian) perspective containing elements of narrative and systems theories. Psychopathology develops when one feels discouraged and incapable of completing the tasks of life which leads to striving toward a position of superiority (Ansbacher & Ansbacher, 1956). Griffith & Powers (2007) described psychopathology by the following quote: “The discouraged person, operating on the useless side of life under the burden of increased feelings of inferiority, makes the error of supposing that his or her task is to attain a position of superiority over others” (p. 99). This does not occur suddenly but rather over time in response to a perception of being incapable in solving ones problems in a socially interested manner (Ansbacher & Ansbacher, 1956). There are two planes of significance representing two directions this striving can move. These are the vertical and horizontal planes of significance. Adler explained that those who strive on the vertical plane have turned against others and their goal is to reach a position of superiority over others (Ansbacher & Ansbacher, 1956). CRITICAL FACTORS 8 In contrast, the horizontal plane is the plane of social interest in which an individual recognizes the demands of living in a socially interested manner seeking perfection over tasks rather than others (Ansbacher & Ansbacher, 1956). So, people naturally want to better themselves but do they do it to obtain a position of superiority over others or do they recognize the demands of communal life and align their goals with the goals of society? We are all socially embedded, and ultimately all problems are social problems. You will find that those who are mentally ill strive on the vertical plane and display a lack of Social Interest. However, Adler believed that no one is completing lacking in Social Interest and they can return toward a socially useful rather than useless side of life. Unfortunately our society places too great of an emphasis on individual achievement which creates a desire for individuals to strive to be better than or greater than others. The notion of Social Interest determining ones level of mental health is not a widely held belief nor is the belief that individuals choose everything they do. What would happen if this knowledge was spread on a mass scale and taken seriously? In a 1929 film from the University of South Carolina Newsfilm Library Adler explained that all individuals that are against society have one thing in common which is a lack of Social Interest. Adler (1929) explained “So we find at last that all the failures in life, problem children, neurotic and psychotic persons, delinquents, suicides, drunkards, and son are always lacking Social Interest. And it is not only this interest but in the same way they are also lacking courage, understanding, and the right training for the solutions of social problems.” Social Interest is more than the act of helping out your neighbor or holding the door for someone because this is what society expects. Rather, it is a genuine concern which cannot be faked. If an individual or society does not truly care for others this cannot be hidden and is reflected by everything we do. This is more than an idea; it is a fundamental cursor of CRITICAL FACTORS 9 mental health that needs to be taken seriously. Our society is a prime example of faking Social Interest. Large corporations, the Federal Reserve banking system which reduces American citizens to a position of slavery, pornography, the idealization of violence, and the condoned rape of women in the United States Air Force represent just a few examples that reflect a lack of Social Interest or concern for others in our society. Furthermore, the United States government at its core is fundamentally flawed as our military enters into other countries without just cause. The most recent example involves our entry into the Middle East in which wealthy Americans lied to the American public and created a war to profit from oil and defense contracts. The construction of military bases in the Middle East and elsewhere in the world reflects Americas striving for power against Social Interest, towards a position of superiority over others masked by a facade of caring for others and the goal of spreading democracy. It is not just corporations and the government who are to blame, all of us could do more to help others. The United States has become a society of egocentrism and excess as we are responsible for more waste than any other country. If we (society) do not start caring for others on this planet and the planet itself, we will perish from the earth. In terms of mental illness and diagnosis Adler distinguished between neurotic and psychotic individuals. Griffith & Powers, (2007) stated that the neurotic’s behavior is expressed with two words;” yes, but” (p.72). Yes, I know what is expected of me but I have this symptom, disorder, or excuse as to why I’m exempt from completing life tasks Thus, neurotics recognize the importance of acting in a socially interested manner but have an excuse or exemption from completing these tasks. The neurotics suffering is real but perhaps they have decided “well if I’m CRITICAL FACTORS 10 going to feel bad I might as well get something out of it.” To ease their suffering they call others into their service for example, through tears which Adler (1956) described as “water power.” Powers and Griffith (2007) described the behavior of individuals who display psychotic behaviors by the word, “no, or the no of psychotic” (Griffith & Powers, 2007, p. 86). They fail to recognize or merely ignore the demands of life and create a fantasy world which may be easier for them to live in than reality (Griffith & Powers, 2007). Psychotic individuals have decided that they do not want to play by the rules of society and so fantasy becomes a way for them to make up their own rules or guiding fictions from which to live out their lives. These individuals often do not wish to let others in to their private worlds because they are afraid of anyone who might criticize or attack the validity of their created realities. All people create Guiding Fictions which they hold to be truth to guide them through their interactions with the world; however the behaviors of individuals who experience psychotic symptoms deviate from those experienced by the person’s culture at large. The reason that psychotics have chosen to create their own worlds can best be explained in the following quote from Alfred Adler. According to Adler psychosis “appears to us as the mental suicide of an individual who does not believe himself adequate to the demands of reality and to his own goals” (Ansbacher & Ansbacher, 1956, p. 323). If a person cannot meet the many expectations that society places on them, which are always increasing, or their own expectations and goals they simply give up or commit a mental suicide as Adler described. This can be seen as a creative solution taken by an individual who is in tremendous pain; it’s as if they are saying “reality will not allow me a place in where I can be significant so I will create my own reality”. This overcompensation leads the individual toward a CRITICAL FACTORS 11 striving to be Godlike as they create their own reality in which they are center of importance (Ansbacher & Ansbacher, 1956). Kurt Adler and Psychosis Alfred Adler’s son, Kurt Adler further elaborated on his father’s theories and in 1979 published an article that described the development of psychosis, specifically of Schizophrenia from an Adlerian perspective. Adler (1979) provides a historical account of how Schizophrenia was perceived by the public and later the psychiatric profession. He explained that historically Schizophrenia was believed to be caused by witchcraft or demonic possession. This contention is still held by some cultures such as Muslim’s even today who do not agree with western conceptualizations of mental illness. Adler (1979) also pointed out that organic and genetic arguments have been strongly believed by the medical and psychiatric community and that when his father claimed to have successfully treated this population his claims were “derogated” (p.147). This raises the question of why schizophrenia is no longer regarded as a disorder treatable by therapy. Mental Illness and Choice The notion that mental illness, including psychosis is chosen seems to be a difficult sell to this day. If therapy is just as or more effective than medication than why is there more emphasis placed on the latter? The answer of course is obvious, money. Those in the business of profiting off the sale of prescription medications want to convince people that they are sick and that they need to take medications for the rest of their lives to alleviate the symptoms of their sicknesses or in this case mental illnesses. There is less profit to be made if an individual is responsible for their actions and able to get better, but is this a fair claim to make? At what point is a person no longer responsible for CRITICAL FACTORS 12 their actions, and when they reach that point whose responsibility does it become? For example, if a man rides a motorcycle without a helmet crashes and suffers from a severe traumatic brain injury. Let us also suppose that two years later this same man after much physical and behavioral therapy starts to recover from his accident and begins displaying depressive symptoms as well as behavioral disturbances. If this man, prior to the motorcycle accident did not display such behaviors and was a generally satisfied with his life and who did not experience clinical depression, is it fair to say that he is now choosing to depress and to anger as Glasser (2000) would say? One could argue that he chose to ride the motorcycle and so was a risk taker and that he chose to take the risk. In Adlerian terms every person has a Lifestyle or a characteristic way of being in the world and in the context of a brain injury one’s Lifestyle becomes scrambled. The man in the motorcycle is trying to act out his Style of Life by utilizing the areas of his brain that aren’t damaged and by interacting with his new environment, which after hospitalization is likely a group home. Would it make any difference if this man had not worn a helmet and perhaps had a death wish or the death instinct as Freud might say? If this latter point were the case then the man chose to accept the consequences of his actions. By following this logic one could argue that those who want to die or take greater risks are more likely to receive a TBI. Regardless of which is the case society has decided that it is our responsibility to provide care for all of these individuals regardless of what they have done to harm themselves or others. These individuals either made an error in judgment or were victims of circumstances beyond their control. The point is that it’s difficult to accept a biological, genetic explanation on one end and on the other 100% free will and choice to explain a person’s CRITICAL FACTORS 13 behavior. After the TBI has been sustained it does not seem fair or possible to hold these individuals accountable for their actions. If the higher functions of their brains are damaged the more primitive areas will take over and the question becomes whether they are still in control of their behaviors. Individual or (Adlerian) psychology is a form of soft determinism meaning that while past events and genetic predispositions may affect subsequent behavior an individual has the right to choose their actions and whether to use mental illness as a solution to the tasks of life (Ansbacher & Ansbacher, 1956). However, the debate of determinism vs. free will is not a new one and to help enrich this debate an example from the philosophy of religion may be useful. There is a philosophical argument which claims that if God is omniscient or all-knowing than free will is an illusion (Slowik, 2006). In laymen’s terms this means that if God knows everything that has and will ever happen then in what sense our are actions truly free? If the world is a stage and humans are actors in a play, God set the stage, he wrote the script, and he has also written everyone’s lines. According to Slowik (2006) since God created humans knowing that everything they would do before they were even created how could anyone do anything differently? The consequence of this line of reasoning is that one can either accept that they have no control over their destinies or that God does not know everything (Slowik, 2006). However, this western conceptualization of God who is capable of transcending time, is all knowing, and all powerful (omnipotent) are characteristics that devout believers are not willing to give up and so the former must be true, i.e. that God does not know everything. But, this is not an acceptable answer to believers either (Slowik, 2006). CRITICAL FACTORS 14 In terms of science, the world was created by the big bang in which something was created out of nothing, an idea that most of us can’t even fathom. From this initial creation in which matter won out over anti-matter and millions or billions of years later humans evolved into the species we are today isn’t the argument the same? Are we not the result of an uncaused cause whether it be God or the universe and if so in what sense are actions truly free if everything we do is predicated on genetics and previous behavior? Either our behavior is determined or we have free will; however there is currently insufficient evidence to prove which is the case and so the most useful option is to believe that we have free will and can choose to do something or choose not to do something. Even the brain injured man in the above example has a choice of using the areas of his brain that are still functioning to contribute to society as much as he is able to. Of course it will be more difficult for him to do so than a person who has not sustained a brain injury, but to give up hope that one can choose to recover and return to a socially interested position is unacceptable. The consequences of accepting a belief in hard determinism are that humans are not responsible for their actions and could not have lived their lives any differently. Thus in terms of mental illness a person chooses to solve their problems in a socially useful way or having given up all hope, chooses to adopt a neurotic or psychotic Lifestyle. How do the terms neurosis and psychosis fit into a discussion of Axis I and II disorders of the DSM-IV-TR? According to Adler all psychopathology stems from the same root cause i.e. feelings of inferiority, as previously mentioned (Ansbacher & Ansbacher, 1956). When individuals feel inferior this leads to discouragement and can result in the development of a mental illness. The disorders in the DSM-IV-TR can be thought of as the different manifestations of an underlying feeling of inferiority. According to Sisk (2010) an Adlerian conceptualization of mental illness CRITICAL FACTORS 15 can be described metaphorically. If mental illness is thought of as a tree the roots represent underlying feelings of inferiority, the trunk is the Lifestyle and the branches then represent the DSM-IV-TR based mental illnesses (Sisk, 2010). People may be genetically predisposed toward a particular mental illness, however that does not guarantee it will develop (this includes Schizophrenia). Individuals choose whether consciously or unconsciously to be mentally ill as this is their best attempt at dealing with life. As mentioned above this represents a view of soft-determinism; while there may be causal factors such as genetics and neurotransmitters that influence the development of psychopathology what also matters is what the creative individual makes of their life experiences. It is also important to note that Adler would say that a person is discouraged rather than mentally ill. An individual has become discouraged about dealing with life rather than this person is ill and so they must be labeled and deemed abnormal by terms such as mental illness. Thus, from an Adlerian perspective GSP and AVPD can be thought of as the creative solutions or positions taken by discouraged individuals, lacking in Social Interest, to solve the life tasks. Adler also distinguished between neurotic and psychotic individuals. Social Phobia and Avoidant Personality Disorder can be described as neurotic disorders whereas Schizophrenia, for example is a psychotic disorder representing a loss of contact with reality. However, the distinction between neurotic and psychotic conditions and DSM diagnosis is not always a clear one. The term borderline in Borderline Personality Disorder initially referred to an individual who was on the border between neurosis and psychosis (Schimelpfening, 2011). Another is example is that there are specifiers in the DSM-IV-TR such as for Major Depressive Disorder (a neurotic disorder) that can be specified with psychotic features (APA, 2000). Although these disorders both appear to be neurotic conditions are they CRITICAL FACTORS 16 the same or similar as the DSM-IV-TR suggests? The first step in attempting to answer this question is to look at the history of this debate which began with the DSM III published by the American Psychiatric Association in 1980. Comparison of DSM Editions The DSM III was the first edition of the DSM to include diagnoses of Social Phobia and Avoidant Personality Disorder (Turner, Beidel, & Townsley, 1992). From the onset of these additions to the DSM there has been confusion as to whether these disorders could be diagnosed together. The DSM III stated that Social Phobia could not be diagnosed if Avoidant Personality Disorder is present (APA, 1980). On the other hand it also stated that when considering a diagnosis of Avoidant Personality Disorder that Social Phobia may be a complication of AVPD meaning that they could co-occur (APA, 1980). This represented a contradiction within the same edition of the DSM. The subsequent editions of the DSM including the DSM III-R, DSM- IV, and DSM-IVTR have also failed to make a clear distinction between these disorders. The DSM III suggested that individuals with Social Phobia had a fear in one phobic situation (APA, 1980). Turner, Beidel, & Townsley, (1992) explained that in the DSM III-R this assertion was revised and introduced a subtype of Social Phobia, the generalized type, which represented the fear “includes most social situations” (p.326) However, as the researchers went on to explain it was not made clear how many situations constituted most situations. Turner, Beidel, & Townsley (1992) suggested that there were 3 Avoidant Personality Disorder criteria that overlap with Social Phobia and these criteria were: 1) avoids social or occupational activities that involve significant interpersonal contact, 2) is reticent in social situations because of fear of saying something CRITICAL FACTORS 17 inappropriate or foolish, or being unable to answer a question, and 3) fears being embarrassed by blushing, crying, or showing signs of anxiety in front of other people. (p. 327) Turner, Beidel, & Townsley (1992) argued that only one additional criterion would be needed as the DSM-III-R required four criteria to diagnose AVPD. However, these authors did not provide information about which Social Phobia criteria were related to this overlap. Unfortunately, the revised DSM-IV-TR by stating that these disorders may actually be the same the APA (2000) has seemingly thrown its hands up in the air and said “we just don’t know.” Since this debate has not been resolved by the APA research must show the critical factors involved in this argument. By presenting the experience of these disorders separately beginning with GSP followed by AVPD these factors can then be identified. Social Phobia According to Comer (2002) anxiety is an evolutionary based natural response of the body to a real or imagined threat. The difference between fear and anxiety Comer explained, is that fear involves a response to a clearly identified threat whereas anxiety involves a general sense of dread that is not necessarily attributed to a specific threat. When this fear becomes distressful, deviant, dysfunctional, or dangerous to an individual clinical concern may be warranted. These four levels are known as the 4 D’s of abnormality and are considered with any mental health diagnosis including Social Phobia (Comer, 2002). Distress refers to whether a particular disorder is upsetting to the individual and deviance illustrates the degree to which a disorder deviates from norms of typical behavior based on the population at large (Comer, 2002). In terms of dysfunction this represents the level a disorder interferes with a person’s day to day functioning such as a person’s ability to complete daily living tasks (Comer, 2002). CRITICAL FACTORS 18 Finally, the level of danger refers to the extent an individual presents a danger to themselves or others. Sole cases of Social Phobia are unlikely to present a danger to anyone; however anxiety disorders are often co morbid with others such as the depressive disorders. The risk of suicide then as is present in depressive disorder would represent such danger (Comer, 2002). The D’s of abnormality are useful considerations to be made both for Axis I disorders such as Social Phobia as well as Axis II disorders such as AVPD. Many perspectives can be taken to explain the etiology of Social Phobia, two of which are neurochemical and behavioral approaches. Selective Serotonin Reuptake Inhibitors (SSRI’s) have been demonstrated to be effective in the treatment of Social Phobia according to Tillfors (2004), however it is not clear whether it truly has an anxiolytic (anti-anxiety) effect or if it actually increases anxiety. Specifically, low levels of serotonin are suggested to be present in individuals with Social Phobia. Tillfors suggested that patients initially treated with such medications may experience these increases in anxiety before the more long lasting effects of the medications occur. Dopamine, or the pleasure center of the brain, is also said to be affected in Social Phobia (Tillfors, 2004). An in depth look at these chemicals are beyond the scope of this literature review. For a detailed explanation of these neurochemical processes as well as information regarding genetic and neuroimaging research Tillfors (2004) should be read in its entirety. From a behavioral perspective both classical and operant conditioning has been suggested to be involved in the adoption and maintenance of Social Phobia (Tillfors, 2004). In terms of classical conditioning when a previously neutral stimulus is paired with an unconditional stimulus it becomes a conditional stimulus (CS) which elicits a conditioned response (CR) (Miltenberger, 2004). For example, if a person has to give a speech (UCS) and they receive criticism (aversive or UCR) leading to a feeling of embarrassment (CR) they will when placed in CRITICAL FACTORS 19 a similar situation come to expect criticism and feelings of embarrassment and so have been classically conditioned (Tillfors, 2004). This fear is then maintained by operant conditioning in which the individual receives negative reinforcement (the removal of an aversive stimulus) by avoiding the feared situation. Tilfors (2004) explained that anxiety is then a signal to the individual that they are in a situation which may cause them pain (Tillfors, 2004). From an Adlerian perspective anxiety is used to prevent others from finding out that they are incapable of dealing with situations and ultimately life (Sperry & Carlson, 1996). While many theories speak of possible causes of Social Phobia the DSM-IV-TR provides specific diagnostic criteria to distinguish individuals with and without this disorder. Social Anxiety Disorder and DSM-IV-TR According to criteria A of the DSM-IV-TR published by the American Psychological Association (APA) Social Phobia 300.23 is characterized by: “A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing” (APA, 2000, p. 456). This fear commonly leads to the experience of panic attacks (Criterion B) (APA, 2000). The DSM-IV-TR describes the features of Social Phobia by the following description: “Common associated features of Social Phobia include hypersensitivity to criticism, negative evaluation, or rejection; difficulty being assertive; and low self-esteem or feelings of inferiority” (APA, 2000, p. 452). While these common features are not included in the diagnostic criteria for GSP they nonetheless seem to parallel earlier conceptualizations associated with AVPD, CRITICAL FACTORS 20 specifically features of low self-esteem (DSM-III) and a view of the self as inferior (criteria 6 in DSM-IV-TR) which are included in current AVPD diagnostic criteria (APA, 2000). In terms of differential diagnosis the DSM-IV-TR makes a distinction between Social Phobia and Panic Disorder without Agoraphobia by the nature of what is feared (APA, 2000). Panic Disorder without Agoraphobia involves a fear or concern of experiencing unexpected panic attacks. Panic attacks can occur in the presence of any disorder including Social Phobia. However, in Panic Disorder without Agoraphobia the fear is of having future unexpected attacks. Individuals with this disorder may fear experiencing an attack in public (a social context) but the fear is not limited to this context. Social Phobia is also differentiated from Obsessive Compulsive Disorder, Post-Traumatic Stress Disorder, and Specific Phobia which involve a fear of a specific object such as snakes, (APA, 2000). A generalized type specifier may be added to a diagnosis of Social Phobia if the fears include both public performance and most social interactional situations (APA, 2000). It is this generalized type of Social Phobia (Social Anxiety Disorder) that is suggested to overlap with the Avoidant Personality Disorder. According to the National Institute of Mental Health, NIMH (2011) Social Phobia has a 12 month prevalence of 6.8% of adults in the United States. Prevalence refers to the number of cases of a particular disorder at a given point in time, in contrast to incidence which refers to the number of new cases in a given period of time such as the number of new cases in a year. The DSM-IV-TR reports that Social Phobia has a lifetime prevalence of 3% to 13% (APA, 2000). Lifetime prevalence refers to whether an individual experiences a particular disorder within their lifetime. According to the DSM III Social Phobia was “apparently relatively rare” (APA, 1980, p. 228). However, it is now considered the most commonly experienced anxiety disorder (Tillfors, CRITICAL FACTORS 21 2004). This claim made by the DSM III indicating that Social Phobia was rare may be related to how the disorders was distinguished from other anxiety disorders at the time. The DSM III identified Social Phobia as a phobic disorder distinguishable from anxiety state disorders (Bogels, et al. (2010). According to Bogels et al. (2010) “the term phobia suggests that similarities with specific phobia, in which avoidance of a circumscribed object, activity, or situation is an essential element of the disorder” (p.171). However, the DSM-IV acknowledged that Social Phobia often included multiple social fears by adding the name, Social Anxiety Disorder in parentheses when listing Social Phobia (Bogels et al. , 2010). Bogels et al. (2010) cautions that if the term phobia is used to describe Social Anxiety disorder this could have the unintended effect of underdiagnosing clients. This may also have been why DSM-III considered Social Anxiety Disorder to be a rare condition. Now that the criteria have been changed and more accurately reflect the true experience of the disorder it is being diagnosed more often. The categorical system of the DSM-IV-TR does not distinguish between levels of severity when describing disorders and this has many ramifications. According to Bogels et al. (2010) research suggests that specifiers for Social Anxiety Disorder do not identify real differences between disorders and that the subtype distinctions are arbitrary. The generalized specifier rather than illustrating qualitative differences between subtypes merely reflects the severity of social anxiety experienced (Bogels, et al. , 2010). A greater number of feared situations indicate a more severe experience of social anxiety. For the reason Bogels et al. (2010) suggested that Social Anxiety Disorder may be better described on a continuum based on severity. Thus, Social Anxiety Disorder may better be expressed in terms of dimensions rather than categorically. CRITICAL FACTORS 22 Ruscio (2010) suggested that social fears are at least 60% prevalent among adults at some point in their lives. Based on this statistic Ruscio (2010) suggests that a dimensional rather than categorical classification system be utilized to diagnose individual’s with Social Anxiety Disorder. A categorical system according to Ruscio does not detect individuals who may be below the threshold of detection and many of them experience the same impairments as those who meet the full criteria of Social Anxiety Disorder. A description of AVPD will lead into a discussion of the critical factors involved in a move from GSP to an experience of AVPD. Avoidant Personality Disorder and the DSM-IV-TR The DSM-IV-TR provides criteria for personality disorders in general describing personality disorders as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. These disorders are manifested in 2 or more of the following areas: cognition, affectivity, interpersonal functioning, and impulse control” (APA, 2000, p. 686). The DSM-IV-TR describes Avoidant Personality Disorder 301.82 as: “A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation beginning by early adulthood and present in a variety of contexts” (APA, 2000, p. 718). According to the DSM-IV-TR Avoidant Personality Disorder has prevalence between .5% and 1% of the population (APA, 2000). This refers to how many people are affected by AVPD at any given time. The National Institute of Mental Health (2011) indicates that AVPD has a 6.8% 12 month prevalence. This means that if in any given 12 month period 6.8% of adults will experience this disorder. Only adults are affected as personality disorders are not diagnosed in children. AVPD is characterized by shyness often beginning in childhood. In normal CRITICAL FACTORS 23 development this shyness typically abates, however in avoidant personalities it increases (APA, 2000). In terms of differential diagnosis as previously described Avoidant Personality Disorder may be similar to Social Phobia. Both disorders are characterized by feelings of inferiority and an avoidance of social situations due to fears of embarrassment or rejection (APA, 2000). The difference may be in terms of the language used to describe the experience of these disorders. The words, marked and persistent fear, are used to describe Social Phobia whereas Avoidant Personality Disorder is expressed as a pervasive pattern of social inhibition. Pervasiveness is a word used to describe the course of all personality disorders. According to Merriam-Webster Online Dictionary (2011) the word, pervade means “to become diffused throughout every part of.” This seems to distinguish these disorders by describing the former as persistent, meaning the fear consistently or perhaps increasingly occurs and the latter as pervasive meaning it affects every or many aspects of a person’s life. The writings of Sperry (2003) further add to this discussion as to the distinction between these disorders focusing on the experience of AVPD. Sperry’s View of Personality Disorders Sperry (2003) described the history of how Avoidant Personality Disorder came to be included in the DSM. He explains that it was included in the DSM-III; however at that time it was believed that the disorder was indistinguishable from other personality disorders such as Dependent Personality Disorder and Schizotypal Personality Disorder (Sperry, 2003). Today, however the American Psychiatric Association recognizes that these disorders are distinct. Schizotypal personalities seem to be content with avoiding social contact whereas avoidant personalities have a strong desire for this social interaction (APA, 2000). Dependent CRITICAL FACTORS 24 personalities according to Sperry (2003) are timid and withdrawn due to a need for attachment in contrast to Avoidant Personalities who are also timid and withdrawn but for a different reason which is a fear of rejection. According to Sperry (2003) a dimensional rather than categorical system of diagnosis for personality disorders will be incorporated into the DSM-5. The current version DSM-IV-TR uses a categorical approach in which one either has a disorder or does not. This diagnosis is made based upon the number of criteria met for a particular disorder. A dimensional approach challenges this classification system as personality traits are considered a style on one end of a continuum and disorder on the other (Sperry, 2003). Sperry (2003) describes five proposed dimensional systems including: “1) a pure dimensional approach, 2) a prototype matching approach, 3) a clinically derived personality prototypes approach, 4) a five-factor model approach, 5) and a two-step psychobiological systems approach” (p.20-21). With the pure dimensional system approach a person can be identified as having a personality trait, disorder, or to be considered to be prototypic (Sperry, 2003). In this system individuals are rated by being checked off if they meet a particular criterion. If a client meets one to three criteria they possess a personality trait. Meeting four or five criteria represents having a personality disorder, and according to Sperry if five to eight criteria are met the disorder is pervasive. If seven to nine criteria are identified as being present then the disorder is said to be prototypic (Sperry, 2003). The problem with these criteria is that they are overlapping. If a client meets the requirement for having a personality disorder they also may qualify as having a pervasive disorder if five criteria are met. Similarly, if seven criteria are met the disorder is both pervasive and prototypic. Sperry does not clarify whether these overlap is intentional and allowed i.e. a person could meet more than one classification simultaneously. CRITICAL FACTORS 25 In the current categorical system of diagnosis Avoidant Personality Disorder is represented by meeting four or more criteria (Sperry, 2003). Sperry explained that a dimensional system, by contrast allows for personality traits to be identified and rather than being diagnosed with a personality disorder a person may simply have traits of a particular personality style. Could this dimensional approach be expanded to include continuums across Axis I and Axis II disorders such as a spectrum between Social Phobia and Avoidant Personality Disorder? Sperry would argue against the adoption of this continuum at least for these particular disorders. He acknowledges the debate as to whether these disorders describe the same phenomena. However, Sperry concludes that current research suggests that these disorders are distinct though they often co-occur. Sperry, (2003) describes personality on a continuum ranging from style on one end and disorder on the other. This represents a range spanning from normality to abnormality. For example, an individual may prefer a set routine, in terms of Avoidant Personality Disorder they exaggerate possible risks of doing something outside of that routine Sperry (2003) explained that another trait vs. disorder comparison is in terms of style the person is “very discrete and deliberate in dealing with others” vs. being “unwilling to get involved with people unless certain of being liked” (p. 61). He also described triggering events that lead to Avoidant Personality Disorder, behavioral, interpersonal, cognitive, feeling, and attachment styles. Sperry also identified parental influences, temperament, the Avoidant Personalities self-view, world- view, and the greatest or optimal DSM-IV-TR criteria in identifying this disorder (Sperry, 2003). According to Sperry (2003) Avoidant Personality Disorder is triggered by “demands for close interpersonal and/or social and public appearances” (p.60). Their style behaviorally is shy and withdrawn, interpersonally these individuals are sensitive to rejection, and cognitively they CRITICAL FACTORS 26 are hyper vigilant. Affectively, they are prone to depression when they do not feel total acceptance by others. They may also experience feelings of depersonalization (Sperry, 2003). Sperry (2003) described the ultimate DSM criterion for this disorder which is an avoidance of interpersonal contact in occupational situations. The ultimate criterion according to Sperry, can be used by clinicians as cause to suspect a particular disorder may be present. What may be of particular interest to Adlerian’s in terms of etiological considerations is that Sperry (2003) described the “parental injunction” as “we don’t accept you and probably nobody else will either” (p.68). This injunction seems to reflect a possible mistaken belief that individuals with Avoidant personalities share. While a continuum model for personality traits vs. disorders may be useful in terms of how personality disorders are conceptualized and subsequently treated it does not solve the debate between Axis I and Axis II disorders. Research conducted by Chambless, Fydrich, & Rodebaugh (2006) has sought to determine what the distinctions are, if any between Axis I GSP an Axis II APD. Distinction between Disorders Chambless, Fydrich, & Rodebaugh (2006) conducted a study to determine if there is a distinction between Generalized Social Phobia and Avoidant Personality Disorder. They cite previous findings that claimed the fear in social situations (Social Phobia) is just one fear that individuals with Avoidant Personality Disorder experience. “In particular, earlier notions of AVPD included the description of such patients as being generally fearful and avoidant of novel situations and repressive of their emotions” (Chambless, Fydrich & Rodebaugh, 2006, p. 16). Another example of the difference in these disorders is that in Avoidant Personality Disorder there is a “difficulty in forming intimate relationships” (Chambless, Fydrich, & Rodebaugh, 2006 p. 8). According to Chambless, Fydrich, & Rodebaugh (2006) this difficulty is CRITICAL FACTORS 27 not experienced in Social Phobia. Furthermore, AVPD is has been suggested as “a problem of relating to persons” while “Social Phobia is largely a problem of performing in situations” (Chambless, Fydrich, & Rodebaugh, 2006, p. 16). These distinctions are highlighted in Table 1 below. Table 1 Characteristic differences between GSP and AVPD Generalized Social Phobia Avoidant Personality Disorder FEAR IN SOCIAL SITUATIONS MANY FEARS IN ADDITION TO SOCIAL SITUATIONS NOT CHARACTERIZED BY HAVING A DIFFICULTY IN FORMING INTIMATE DIFFICULTY IN FORMING INTIMATE RELATIONSHIPS RELATIONSHIPS A PROBLEM OF PERFORMING IN A PROBLEM OF RELATING TO PERSONS SITUATIONS One Disorder on a Spectrum In the current study Chambless, Fydrich, & Rodebaugh (2006) compared participants diagnosed with GSP who also experienced AVPD. They hypothesized that participants with comorbid GSP and AVPD experienced more severe Social Phobia compared to those with a sole diagnosis of AVPD. These diagnoses were based on SCID or structured clinical interview for the DSM-III-R. The sample consisted of 55 participants, 34 female of which were female and 21 male. CRITICAL FACTORS 28 In terms of age the participants ranged from 20 to 60 years old with ethnicities of 73% Caucasian, 22% African American, and 5% Asian or Latino. Thirty six of the 55 participants or 65% experienced co morbid Social Phobia and Avoidant Personality Disorder. A limitation of this study was that there was not a group with a sole diagnosis of AVPD. Perhaps this is due to the fact that there really is no such group in existence, i.e. AVPD may not exist without Social Phobia (Chambless, Fydrich, & Rodebaugh, 2006).Participants were measured by self-report questionnaires, and role play measures. A one-way ANOVA of the self-report questionnaires confirmed the researcher’s hypothesis that participants with co-morbid GSP and Avoidant Personality Disorder reported significantly higher levels of social phobia compared those diagnosed with only GSP. For this test the significance was “[F(1,53)=8.16, P=.006]” (Chambless, Fydrich, & Rodebaugh, 2006 p. 13). The researchers report that the effect size was close to large for this test. Role-Play measures were used to determine the participant’s level of social skills by opposite sex confederates and were based on the Social Performance Rating Scale. Chambless, Fydrich, & Rodebaugh (2006) hypothesized that subjects diagnosed with AVPD would have poorer social skills than subjects diagnosed with GSP alone. The results showed that the participants with co morbid GSP and AVPD experienced higher levels of anxiety and negative thoughts compared to those with a sole diagnosis of GSP but this result though close was not statistically significant “[F(4,33)=2.32; n2=0.21;P=.08]” (Chambless, Fydrich, & Rodebaugh, p. 14). From the results of these tests and others such as cluster analyses not reported in this literature review they concluded that “Thus, overall, regardless of the methodological approach used, the most parsimonious conclusion to be drawn from these data is that AVPD, at least as defined by the DSM, should be considered a severe form of GSP rather than a separate CRITICAL FACTORS 29 diagnosis” (Chambless, Fydrich, & Rodebaugh, p. 16). They do acknowledge this point, however that due to a small sample size this can only be concluded for this particular group of participants (Chambless, Fydrich, & Rodebaugh, 2006). Other studies have demonstrated that subjects with AVDP differ on levels of depression. According to Huppert, Strunk, Ledley, Davidson, & Foa (2008) individuals with co morbid GSP and AVPD experienced higher levels of depression and more severe social phobia on self-report measures at an alpha level of p<.05. Another study by Turner, Beidel, & Townsley (1992) concluded that the subjects in their study differed in only one area, depression. Individuals with co morbid GSP and AVPD had higher scores on the Beck Depression Inventory than those with GSP alone “M=70.4 vs. M=59.3, p<.05” (Turner, Beidel, & Townsley, 1992, p. 392). The results of these studies show that similar findings have been found across studies. These studies simply scratch the surface of the available research on the spectrum debate of GSP and AVPD and taken alone cannot claim to resolve this debate. They do however; provide statistically significant findings elucidating which critical factors may be involved in a move from GSP to an experience of AVPD. Critical Factors and Discussion A critical factor that leads an individual from an experience of GSP to AVPD is the severity of their symptoms. Individuals with co morbid GSP and AVPD experience more severe Social Phobia than those with GSP alone. They also experience more severe depression and fear a greater number of situations. This has lead researchers to conclude that AVPD is an extreme form of GSP. Furthermore, according to Griffith, Powers, & Sperry (2006) the antidepressant medication Effexor has been shown to be effective in treating APD traits; however these authors do not indicate the degree of effectiveness. CRITICAL FACTORS 30 Since antidepressants are used to treat GSP this would suggest that these conditions are the same since they are effective in treating both conditions. Griffith, Powers, & Sperry (2006) suggest that the only difference in these disorders is quantitative which supports the contention that AVPD is merely an extreme form of GSP. Based on current DSM-IV-TR criteria it seems that these disorders cannot sufficiently be distinguished from each other and that they fall on a spectrum with AVPD on the severe end. However, there has also been disagreement as to whether the DSM-IV-TR criteria represent the true experiences of GSP and AVPD (Chambless, Fydrich, & Rodebaugh, 2006). Specifically, it has been argued that a core feature of AVPD, low levels of self-esteem, was removed DSM-III criteria and is not included in current DSM-IV-TR criteria (Chambless, Fydrich, & Rodebaugh, 2006). However, according to the DSM-IV-TR low self-esteem is currently also characteristic of GSP as described in the common associated features of Social Phobia (APA, 2000, p. 452). If low self-esteem is associated with both disorders this characteristic may present a complication in distinguishing them. Secondly, another core difference between GSP and AVPD may be that individuals with GSP have difficulty performing in social situations while those with AVPD experience difficulty in forming intimate relationships (Chambless, Fydrich, & Rodebaugh, 2006). Five of the seven criteria for AVPD seem to overlap with Social Phobia. These criteria are 1, 2, 4, 6, and 7, whereas only two criteria, 3) “shows restraint within intimate relationships because of the fear of being shamed or ridiculed” and 5) “is inhibited in new interpersonal situations because of feelings of inadequacy” appear to reflect a difficulty in forming intimate relationships (APA, 2000, p. 295). For a complete description of the diagnostic criteria please refer to the DSM-IV-TR. CRITICAL FACTORS 31 The characteristic of having difficulty in forming intimate relationships seems to provide a clear core distinction between these disorders as it separates their true essences. Based on this argument these disorders are indeed distinct. However, for the past 32 years since the publication of the DSM III in 1980 to the present DSM-IV-TR released in 2000 the American Psychiatric Association has failed to make this distinction. A meta-analysis and review of the available research on this topic must be completed by the DSM V Task Force to ensure that this debate is resolved before the publication of the DSM V. In order for clinician’s to provide accurate diagnoses of their client’s symptoms the diagnostic criteria must be changed sufficiently to distinguish between these disorders. Arguments for a Dimensional Shift in DSM Diagnosis Before an argument can be made supporting the adoption of a model of diagnosis a description of the purpose of diagnostic assessment must first be explained. According to Kamphuis & Noordhof (2009) the DSM has 3 main goals which are: “1) developing international concepts of psychopathology, 2) make expert decisions on whether a disorder is present or not, and 3) make decisions about treatment” (p. 294). The current version of the DSM uses a categorical system of diagnosis in which one either has a disorder or does not. This is determined by narrowly defined criteria which are then counted and if a person meets an arbitrary cutoff score then they are diagnosed with a particular disorder. While there are many criticisms of this current model there are benefits to such a system. For example, Kamphuis & Noordof (2009) explained that clinicians argue that communication is easier, that is in comparison to the alternative system of dimension. Furthermore, if the DSM-5 were to keep the categorical system this would ensure continuity during this transition between editions. This claim seems to suggest that there are certain individuals who do not like the idea of CRITICAL FACTORS 32 change and are subscribing to the philosophy of “if it ain’t broke don’t fix it” or perhaps “well, this is the way we’ve always done things.” The problem with such a position is that the system is flawed and empirical research supports the adoption of a dimensional model. Dimensional models have greater statistical power, reliability, and can be made to meet the needs of diagnostic assessment (Kamphuis & Noordhof, 2009). Bernstein (2011) described the progression of the DSM from the DSM-III released in 1980 to the current DSM-IV-TR revision to set up an argument for DSM-5 to shift towards a new classification system. According to Bernstein (2011) the DSM-III was the first DSM edition to operationalize diagnostic criteria. Due to an increase in the prescription of psychotropic medications there also became a need to have greater inter-rater reliability between clinicians and researchers. Reliability refers to the degree to which a psychometric test measures similar or consistent results across measurements. Conversely inter-rater reliability refers to whether different clinicians or researchers are finding similar results using the same tests (Bernstein, 2011). In contrast validity refers to whether an assessment truly measures what its purported to measure. Bernstein (2011) explained that the DSM diagnoses have been “reified” meaning that they are described as if they exist in reality. This is due to the push for mental illnesses to be conceptualized and diagnosed as it is done in the medical field. Cancer actually exists in reality but does a DSM diagnosis? It seems that we might be cleaving to concepts that do not actually exist. Due to the high rates of co-morbidity between diagnoses and the not otherwise specified catch all diagnoses there is great concern that these disorders may not be reflect clients true experiences (Bernstein, 2011). The increase in reliability according to Bernstein (2011) has come at the cost of validity and the solution is to move towards a new classification system. In this CRITICAL FACTORS 33 same vein the DSM, according to Clercq, Fruyt, Leeuwen, and Mervielde (2006) the DSM has failed to explain the connection between traits found in childhood with adulthood personality disorders. Clercq et al. (2006) proposed that “a specific child maladaptive trait taxonomy further offers a useful framework to incorporate a developmental perspective in the construction of the DSM-5” (p. 639). This argument is beyond the scope of this review and should be read in its entirety. However, it provides another example of how the APA seeks to hold onto an arbitrary separation between Axis I and Axis II disorders, a separation that is contradicted by research. This system, a quantitative dimensional approach, rather than categorical conceptualization of mental illness should be applied not only to personality disorders but to Axis I disorders as well. However, Bernstein (2011) explained that this will likely not happen by the time the DSM V in 2013. She explained that the DSM-5 will be a working document which can be added to as new research and conceptualizations become available. The question becomes how often the DSM-5 will be updated to reflect these changes. With our societies progression towards reading texts on electronic devices such as book readers perhaps physical paper texts will become obsolete. If the DSM V will be constantly revised this change may be necessary and clinicians could simply download updated versions of the DSM based on the most up to date research. This proposed shift for the entire DSM to move towards a dimensional model is described by Bernstein (2011) as the process of meta-structure. By combining or clustering current DSM diagnoses these cluster factors can be tested against each other. This could revolutionize the way mental illness is conceptualized and diagnosed and may solve the problems of overlap between disorders (Bernstein, 2011). CRITICAL FACTORS 34 According to Krueger and Eaton (2010) personality disorders were placed on a separate axis (II) so that clinicians would consider client’s personality characteristics in addition to any Axis I clinical diagnoses. This is an interesting point because it shows that the distinction between axes was not due to fundamental differences between clinical conditions and personality disorders, but rather that this separation is arbitrary. Krueger and Eaton (2010) also point out that while personality traits can be listed on Axis II there is no system for how to classify these traits other than by referencing 1 of the 10 DSM-IV-TR personality classifications. According to Krueger and Eaton (2007) explain that there is no evidence that “the latent structure of personality is best characterized by 10 categorical entities” (p. S66). The concept of latent structure of personality refers to the state of particular personality characteristics lying dormant in a person or that they are present but not readily visible. In terms of the DSM-IV-TR based categorical diagnosis Krueger & Eaton (2010) are suggesting that these 10 types do not sufficiently distinguish one person’s personality from another’s. For this reason a new system is needed and Krueger & Eaton (2010) explain that DSM V investigators have described a new model of personality, the pathological five model or PFM. The PFM extrapolates from the empirically significant 5 factor model of personality which can be recalled by used the pneumonic device OCEAN. These five factors include: openness to experience, conscientiousness, extraversion, agreeableness, and neuroticism (Krueger & Eaton, 2010). In the DSM-IV-TR categorical system of diagnosis a person either meets the criteria for a disorder or they do not. When a personality disorder is diagnosed within this system cutoffs are used, for example 5 of 9 criteria must be met to receive a particular personality disorder diagnosis (Krueger & Eaton, 2010). The problem is that this cutoff is arbitrary and not based on CRITICAL FACTORS 35 clinical data but rather because 5 is more than half of 9. The authors go on to claim that more consideration to personality traits must be added to the DSM V (Krueger & Eaton, 2010). Krueger and Eaton (2007) Three years prior to this article Krueger et al. (2007) argued that personality disorder research shows that dimensional and categorical implementations of diagnosis are needed. Furthermore he claimed that “implementation will likely be more successful if it is an orderly and logical progression from the DSM-IV-TR” (p. S 65) If research does indeed confirm the need for such a system Krueger’s point seems obvious. However, he seems to be pointing out that the APA, who is responsible for making such changes shouldn’t try to completely reinvent the wheel with the DSM-5 revision. Rather the transition should be made as smoothly as possible as this is a new way of doing things. Acceptance by clinicians will be more likely if they can see that a change to a categorical/dimensional system will build on or add to the diagnostic process. Kruger et al. (2007) pointed out that clinicians like the current prototype system because there are 79 diagnostic criteria across the 10 available personality disorder diagnoses. Therefore, if clinicians are to accept a new dimensional system they need to see that it will be easier, more accurate, and time efficient, etc… However, one could also argue that they will have no choice as the DSM is the most widely used an accepted diagnostic manual for mental disorders other than the International Classification of Diseases, (ICD). Personality Disorders and DSM-V According to the American Psychiatric Association (2012) the DSM-5 is scheduled to be released in May of 2013 and the most current proposed revisions of how personality disorders will be conceptualized is now available. The DSM-5's definition of personality disorders in general will also change and there will be a combination categorical-dimensional hybrid system CRITICAL FACTORS 36 of diagnosis for PD's (APA, 2012). The essential features of a personality disorder in DSM-5 are defined as: “impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits” (APA, 2012). The continuum of self includes the areas of self and identity and continuum of interpersonal includes empathy and intimacy. Each of these dimensions is measured on a five point scale from 0 to 4 (APA, 2012). The DSM-5 diagnosis of personality disorders will include a determination of whether impairments in personality are present or not and whether one of the specific subtypes of personality disorder are present or not (APA, 2012). The general diagnostic criteria of personality disorders for DSM-5 which has been significantly revised from the previous DSMIV-TR edition will correlate with the new dimensional system (APA, 2012). Unlike the DSMIV-TR the general characteristics for all personality disorders will aid clinicians in their diagnoses when the presence or absence of impaired personality traits is determined. By contrast the DSM-IV-TR’s general diagnostic criteria were not used when diagnosing clients are were not based on empirical evidence (APA, 2012). Three of the PD types, Schizoid, Dependent, and Histrionic will be removed; however the APA (2012) has not offered an explanation as to why these disorders will not be included in the DSM-5. The DSM-IV-TR indicated that individuals who do not meet enough criteria to be diagnosed with one of the 10 specific types, but who display traits of more than one personality disorders should receive a diagnosis of Personality Disorder not otherwise specified (NOS). The fact that Personality Disorder NOS is the most common diagnosed personality disorder reflects the fact that change is needed (APA, 2012). One such change will include the removal of the NOS specifier for personality disorders (APA, 2012). CRITICAL FACTORS 37 The NOS specifier will be removed as it does not provide clinical utility in terms of distinguishing one client diagnosed with Personality Disorder NOS from another (APA, 2012). If a client is not diagnosed with one of the six types they will be diagnosed with Personality Disorder Trait Specified (PDTS) measured by the Levels of Personality Functioning Scale. The PDTS scale will replace the NOS specifier and is an improvement because unlike the NOS specifier the PDTS designation will reveal quantitative differences between others diagnosed with PDTS (APA, 2012). Avoidant Personality Disorder and DSM V As previously mentioned DSM-5’s general diagnostic criteria for personality disorders will involve the identification of impairments of personality functioning in both self and interpersonal areas (APA, 2012). These areas are specifically defined by each disorder including AVPD. Additionally, there have been significant changes made to the specific diagnostic criteria for the Avoidant Personality Disorder type. The DSM-IV-TR indicates that 4 or more criteria must be met to diagnosis AVPD, however according to the APA (2012) the DSM-5 proposes that in order to diagnose AVPD “the following criteria must be met.” By not designating a cutoff score of how many criteria must be met this suggests that all criteria will need to be met to diagnose AVPD. Features of low self-esteem have been added back to the DSM-5 criteria after being removed during the revision from DSM-III-R to DSM-IV. This feature has been added under identity functioning and combined with DSM-IV-TR criteria, the new criteria states “low self-esteem associated with self-appraisal as socially inept, personally unappealing, or inferior, excessive feelings of shame or inadequacy” (APA, 2012). Features of low self-esteem have been considered by researchers as a characteristic distinguishable from SAD and adding it back to the criteria for AVPD increases the chances for CRITICAL FACTORS 38 sufficiently separating the two disorders. A second impairment in personality functioning under the heading self-functioning includes self-direction which involves a person’s capacity to take risks and pursue goals (APA, 2012). Interpersonal functioning is described by impairments in empathy and intimacy. According to the APA (2012) impairments in empathy include: “preoccupation with, and sensitivity to, criticism or rejection, associated with distorted inference of others perspectives as negative.” In addition to impairment in personality AVPD criteria also includes the presence of pathological personality traits in the domains of detachment and anxiousness (APA, 2012). Detachment includes 3 facets which are withdrawal, intimacy avoidance, and anhedonia. Withdrawal involves “reticence in social situations; avoidance of social contacts and activity; lack of initiation of social contact.” What the criteria do not explain is the reason individuals with AVPD engage in these behaviors. The empathy and intimacy impairments described above suggest that these individuals are reticent in social situations. In terms of the empathy impairment individuals are preoccupied with criticism and rejection and perceive others as negative but why? On the other hand the intimacy impairment indicates that individuals with AVPD will not get involved with others unless there is a certainty that they will be liked due to fears of shame and ridicule. This criterion at least gives a reason, but it is unclear if this reason also applies to the withdrawal criterion as well. According to the APA (2012) intimacy avoidance involves “avoidance of close or romantic relationships, interpersonal attachments, and intimate sexual relationships” and again there is not reasoning given for this. Anhedonia is the 3rd and final pathological personality trait included under detachment criteria and involves a “lack of enjoyment from, engagement in, or energy for life’s experiences; deficits in the capacity to feel pleasure or take interest in things” (APA, 2012). Anhedonia or CRITICAL FACTORS 39 lack of interest in activities that were previously enjoyable is a symptom of depression, an Axis I condition and represents over-lap between Axis I and Axis II. If the person never experienced any joy perhaps a distinction could be made, however it is hard to believe that a person’s life has been completely without joy. A description of the changes in Social Anxiety Disorder criteria will add to this debate, followed by a discussion of whether the changes between SAD and AVPD will distinguish between these disorders. Social Anxiety Disorder and the DSM V There have been several proposed revisions made by the American Psychiatric Association DSM-5 (2012) for how Social Anxiety Disorder (SAD) will be both conceptualized and diagnosed. It is important to note that these proposed revisions do not represent the final draft of the DSM-5; however they may be utilized speculatively as the most recent available information about where the conceptualization of this disorder is headed. In previous DSM editions including the most recent edition of the DSM-IV-TR this disorder is listed as Social Phobia (Social Anxiety Disorder). However, in the DSM-5 this will be reversed and the disorder will be listed as Social Anxiety Disorder (Social Phobia) (APA, 2012). The rationale behind this change is to avoid confusion between Social Anxiety Disorder and Specific Phobia. According to the APA (2012) criterion A has been changed by removing the word persistent and describing “marked fear or anxiety.” These terms (marked fear and anxiety) will be used to describe all anxiety disorders including SAD as research suggests they are core features all anxiety disorders (APA, 2012). Three types of social interactions have been identified by the new DSM-5 criteria and include: interaction, observation, and performance (APA, 2012). The addition of these 3 identified types of situations may eliminate the ambiguity in DSM-IV-TR criteria describing a CRITICAL FACTORS 40 fear in most social situations by specifically outlining which types of situations are typically feared. Additionally, the DSM V will not include a generalized specifier for SAD. In the DSMIV-TR the phrase show anxiety symptoms was placed in brackets in criterion A and these brackets will be removed by the DSM-5 as they are a core feature of all anxiety disorders. Additionally the terms humiliating and embarrassing will be placed in brackets as examples of the broader term negative evaluation because this term more accurately describes this core fear in SAD. This phrase will also be moved from criterion A to Criterion B in the DSM-5 (APA, 2012). Criterion B in the DSM-5 describes a fear of showing anxiety symptoms in front of others and in other cultures the reason for this fear may be different (APA, 2012). To account for this difference the DSM-5 acknowledges this difference in the SAD criteria by adding the phrase or will offend others to criterion B. Another proposed revision is to increase the number of diagnostic criteria for SAD from eight to 10. Specifiers for SAD will also change, starting with the removal of the generalized type specifier and the addition of a performance only specifier which is defined by a restricted fear of performance situations only (APA, 2012). The removal of the generalized specifier type superficially resolves the debate as to whether Generalized Social Anxiety Disorder and Avoidant Personality Disorder are the same or similar disorders since it will no longer be an available diagnosis. However, further discussion is needed to determine whether the DSM-5 will sufficiently reconcile the debate. Another specifier, selective mutism will also be added to the SAD criteria. An individual with selective mutism is unable to speak in situations where speaking is expected but they are able to speak in other situations (APA, 2012). Selective mutism has previously been listed in the DSM as a separate disorder, however research has suggested that CRITICAL FACTORS 41 due to the high co-morbidity found between this disorder and SAD that selective mutism is a potential manifestation of SAD. For this reason selective mutism will no longer be an available as a separate diagnosis. DSM-IV-TR criterion F indicates that the symptoms of SAD must be present for at least 6 months for individuals less than 18 years of age (APA, 2000). The DSM-5 proposes that the age restriction be removed (APA, 2012). Due to this change all individual that experience symptoms of SAD will not qualify for diagnosis of the disorder until these symptoms are present for at least 6 months, regardless of age (APA, 2012). Since social anxiety is a relatively common phenomenon it is important that this duration criterion be present so that transient social anxiety is not misdiagnosed as SAD. The term transient according to Merriam Webster (2012) refers to the quality of passing especially quickly into and out of existence. In terms of SAD this means that social anxiety may manifest itself and then quickly abate, and so a hasty diagnosis is not warranted. Criterion C from the DSM-IV-TR which states that “the person recognizes that the fear is excessive or unreasonable” will also be removed (APA, 2012). It has been determined that clients are not good at judging whether their fears are excessive are unreasonable, instead clinician’s will now make this determination (APA, 2012). Does DSM V end the Continuum Debate? According to the DSM-IV-TR “there appears to be a great deal of overlap between Avoidant Personality Disorder and Social Phobia, Generalized Type, so much so that they may be alternative conceptualizations of the same or similar disorders.” Since the publication of the DSM III there have been contradictory explanations of how to interpret the experience of these orders, whether they can coexist, or if they are distinct. Due to the fact that the DSM is currently CRITICAL FACTORS 42 a categorical system of diagnosis clinicians must be able to provide clear distinctions between these disorders and up until this point it has failed to do so. This review of the literature has sought to determine whether these disorders are indeed distinct and the answer to the consequences of this determination go beyond theoretical debate as they have implications on clinical practice. The DSM-5’s proposed revisions to the diagnostic criteria for Social Anxiety Disorder (SAD) and Avoidant Personality Disorder (AVPD) will end this debate on at least one level, i.e. the removal of the generalized specifier for SAD. It was this specific type of SAD that was said to overlap with AVPD. The DSM-5 will add two new specifiers to its criteria which are selective mutism and performance only subtypes. The core feature of SAD is a fear of displaying anxiety symptoms in front of others and a fear of one or more social situations in which one may be scrutinized by others. Three types of social situations have been identified by DSM-5 criteria and these are: interaction, observation, and performance situations. This distinguishes SAD from AVPD by focusing attention on the core experience of the disorder which is a fear of scrutiny in performance situations. By contrast the core features of AVPD include a fear of interpersonal relationships and feelings of low self-esteem. Low self-esteem has been argued to be a core feature of AVPD, however it was removed from the DSM after the DSM-III-R. Fortunately, features of low self-esteem will be included in the DSM-5 criteria. Clinical Implications The Diagnostic and Statistical Manual of Mental Disorders (DSM), originally published in 1956 has sought to create a reference guide that would be useful to clinicians and researchers to describe the psychopathologies observed in practice. By seeking agreement about the CRITICAL FACTORS 43 experience of these identified disorders the best course of action can then be administered. Subsequent additions of the DSM have attempted to objectify psychology and validate it as a legitimate science comparable to the medical model. The DSM up through the current DSM-IVTR uses a categorical classification system of diagnosis in which one either meets the criteria for a mental health diagnosis or they don’t. This system is flawed as there is considerable overlap between disorders through comorbidity and the overuse of the not otherwise specified diagnosis. This overlap reflects a fundamental flaw in the system, which is that people do not fit neatly into prescribed categories and each individual’s experiences are unique. The categorical system attempts to mirror the medical model by identifying these specific criteria or symptoms as if the disorders exist in reality. The problem with this reasoning is that mental illness is fundamentally different than medical illness in that the disorders described by the DSM-IV-TR are based on theories of latent structure meant to be used as a guide and are not entities that exist in reality. The primary focus of this literature review was to describe the overlap between Generalized Social Anxiety Disorder and Avoidant Personality Disorder. However, in the grand scheme of things it is merely an example of a flawed system and one must ask themselves, why do I even need to care if there is a difference between these disorders? This is a valid question and the answer is because if you work in the mental health field, there are many reasons. For example, the DSM-IV-TR is the most widely accepted diagnostic reference guide currently in use other than the International Classification of Diseases and if we (clinicians, researchers, etc.) must use this system than it had better be accurate. The key words in the previous sentence are reference guide, the manual is a tool to aid clinicians in understanding their clients behaviors. However, this is not the only reason the DSM-IV-TR is used, it is also used to receive insurance CRITICAL FACTORS 44 reimbursements, research money, and to feed the money machine that profits from the sale of psychotropic medications. Consider for a moment the process that an Adlerian therapist would take in diagnosing a client and furthermore let’s assume that this therapist only accepts out of pocket payments, i.e. they do not accept insurance. Treatment in the Adlerian model is the same regardless of who the client is or what their symptoms are and diagnosis is not reached from looking in a reference guide. While in Adler’s time this may have been common practice today some might consider this blasphemous as the DSM is the bible and you better believe in it. Diagnosis in Adlerian therapy involves a Lifestyle Assessment, which includes an analysis of a client’s family of origin, early recollections, dreams, and birth order. From this assessment which is collaboratively undertaken with the client, the client’s beliefs about self and the world can be elucidated. This leads to insight in which the client learns how their Lifestyle impacts their lives and the choices they make in the pursuit of their goals. From this awareness clients can then choose to hold onto beliefs that are useful and change those that are not. Now imagine that you’re a clinician and you’ve received a referral from a colleague who has been diagnosed or labeled with Borderline Personality Disorder. A diagnosis has already been made, likely by a psychiatrist who even though personality disorders can’t be treated with medications, but guess what? She takes medications because if an Axis II disorder is present there must be an Axis I so we can get her to take meds for that one. Since you don’t have to worry about diagnosing your new client one of the next things you might think of is how you will treat this person and likely the first thing that pops into your mind is DBT because its known as the gold standard for treating borderline clients. If you’re an Adlerian or even a cognitive behavioral therapist who is not specifically trained in DBT then you CRITICAL FACTORS 45 might not even agree to see this client because the help they need is beyond your level of competency. However, perhaps the organization you work for says you don’t have a choice and must see this client. The first thing you can do is throw the DSM out the window because it’s not going to prepare you for how difficult that client is going to be from the moment you meet him or her until the moment therapy terminates. The DSM-IV-TR does not offer much help in the way of treatment advice; instead it gives you labels to put on someone so that insurance companies will pay for them to receive therapy, beyond that you don’t need it. This of course is an extreme position which no one would ascribe to but its absurdity takes away some this great emphasis that is placed on diagnosis. Clinician’s need to be able to accurately diagnose clients and the current system does not allow for this. The problem is that clients don’t fit into neat little categories or types that are distinct from each other and so if clinicians are made to use a reference guide than it should be made to more accurately reflect and describe the experiences of clients. The DSM-5 task force has begun this process with the adoption of a hybrid categorical/dimensional model of personality functioning, however they are currently unwilling to expand this model to Axis I disorders. They (the APA) are cleaving to the traditional categorical system of diagnosis even though many of the same problems exist on Axis I such as high levels of co-morbidity between disorders and the NOS specifier. Furthermore, there exists a contention that Axis II personality disorders are fundamentally different from Axis I disorders and this is the justification used for why the DSM-5 will use the new categorical/dimensional hybrid model for personality disorder diagnosis only. Let’s say that a client was diagnosed with Major Depressive Disorder at the early age of 6 and this disorder persists throughout the rest of their lives. The DSM terminology would CRITICAL FACTORS 46 describe this Axis I condition as persistent, however personality disorders are described as pervasive. Couldn’t a depressive disorder that persisted throughout a client’s entire life have been described as pervasive? Pervasiveness refers to the quality of affecting every area of a person’s life and depression definitely affects all areas of life. One could argue that a depressive isn’t always in a depressive episode and can experience “normal” periods of functioning. However, the same argument could be made for a borderline, which is that borderlines experience symptoms of transient anger and psychotic episodes but these do not occur all of the time. From another perspective the question could be posed, “how could it hurt?” If a dimensional component were added to Axis I disorders all were really saying is to quantifiably reflect severity. The DSM-IV-TR attempts to describe severity categorically by distinguishing conditions such as Dysthymia and Major Depressive Disorder, for example. Dysthymia describes a patient with less severe depression and so one either has moderate depression (dysthymia) or severe depression (Major Depressive Disorder). Conversely this can be seen in the distinction between Bipolar I and Bipolar II. Specifiers are also used to describe mild, moderate, severe, and chronic types of Axis I disorders but don’t tell you how much numerically. The current system does also not allow for a conceptualization of functioning to be considered as normality on one end and psychopathology on the other as Sperry (2003) suggested. If a client’s mental health is measured and describe their functioning as normal than they cannot receive treatment, at least not through 3rd party reimbursement. The consequence of this is that clinicians must look for pathology. The distinction made between Axis I and Axis II disorders seems to be arbitrary and does not account for problems of co-morbidity, between or within axes. By adding a dimensional component to the diagnosis of Axis II personality disorders the DSM-5 has made a step in the right direction. CRITICAL FACTORS 47 However, it seems that the addition of a dimensional conceptualization of Axis I disorders would be greatly beneficial. CRITICAL FACTORS 48 References Adler, A. (1929). MVTN 3-62. The University of South Carolina Newsfilm Library. Retrieved from http://www.youtube.com/watch?v=PUnSXbb5eQ8. Adler, K. (1979). An Adlerian view of the development and treatment of schizophrenia. Journal of Individual Psychology, 35(2), 147-162. American Psychiatric Association. (2012). DSM V: The future of psychiatric diagnosis. Retrieved from http://www.dsm5.org/Pages/Default.aspx. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, (4th ed., text revision). Washington, DC: Author. American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders, (3rd ed.). Washington, DC: Author. Ansbacher, H. L. & Ansbacher, R. R. (1956). The individual psychology of Alfred Adler. New York, NY: Harper & Row, Publishers, Inc. Bernstein, C. (2011). Meta-structure in DSM-5 process. Psychiatric News, 46, 7-29. Bogels, S. M., Alden, L., Beidel, D. C., Clark, L., A., Pine, D. S., Stein, M. B., & Voncken, M. (2010). Social anxiety disorder: Questions and answers for the DSM-5. Depression and Anxiety, 27, 168-189. Chambless, D. L., Fydrich, T., & Rodebaugh, T. L. (2006). Generalized social phobia and avoidant personality disorder: Meaningful distinction or useless duplication? Depression and Anxiety, 25, 8-19. Clercq, B., Fruyt, F. D., Leeuwen, K. V., & Mervielde, I. (2006). The structure of maladaptive personality traits in childhood: A step toward an integrative developmental perspective for DSM-5. Journal of Abnormal Psychology, 115(4), 639-657. CRITICAL FACTORS 49 Comer, R. J. (2002). Fundamentals of abnormal psychology, New York, NY: Worth Publishers. Dreikurs R. & Soltz. V. (1964). Children: The challenge. New York, NY: Penguin Books USA Inc. Glasser, W. (2000). Counseling with choice theory: The new reality therapy. New York, NY: HarperCollins Publishers INC. Griffith, J., & Powers. R. L. (2007). The lexicon of Adlerian psychology. Port Townsend, WA: Adlerian Psychology & Associates, Ltd., Publishers. Griffith, J., Powers, R. L., & Sperry (2006). Biopsychosocial Issues. The Journal of Individual Psychology, 62(3), 324-337. Kamphuis, J. H., & Noordhof, A. (2009). On categorical diagnoses in DSM-5: Cutting dimensions at useful points? Psychological Assessment, 21(3), 294-301. Kreuger, R. F. & Eaton, N. R. (2010). A personality trait model for the diagnostic and statistical manual of mental disorders (DSM): The challenges ahead. Personality Disorders: Theory, Research, and Treatment, 1(2), 135-137. Kreuger, R. F. & Eaton, N. R. (2010). Personality traits and the classification of mental disorders: Toward a more complete integration in dsm-5 and an empirical model of psychopathology. Personality Disorders: Theory, Research, and Treatment, 1(2), 97-118. Krueger, R. F., Skodol, A. E., Livesley, J. W., Shrout, P. E., & Huang, Y. (2007). Synthesizing dimensional and categorical approaches to personality disorders: Refining the research agenda for DSM-5 axis ii. International Journal of Methods in Psychiatric Research, 16(S1), S65-S73. Merriam-Webster Online Dictionary. (2011). Retrieved from http://www.merriamwebster.com/dictionary/pervade. CRITICAL FACTORS 50 Miltenberger. R. G. (2004). Behavior modification principles and procedures. Belmont, CA: Wadsworth & Thomson Learning, Inc. National Institute of Mental Health. (2011). Avoidant personality disorder statistics. Retrieved from: http://www.nimh.nih.gov/statistics/1Avoidant.shtml. National Institute of Mental Health. (2011). Social phobia among adults statistics. Retrieved from: http://www.nimh.nih.gov/statistics/1SOC_ADULT.shtml. Ruscio, A. M. (2010). The latent structure of social anxiety disorder: Consequences of shifting to a dimensional diagnosis. Journal of Abnormal psychology, 119(4), 662-671. Schimelpfening, N. (2011). Borderline personality disorder. Retrieved from: http://depression.about.com/od/glossary/g/bpd.htm. Sisk, J. (2010). A lecture to her students in Psychodynamics of Psychopathology at Adler Graduate School: Richfield, MN. Slowik, E. (2006). A lecture to his students in Philosophy of Religion at Winona State University: Winona, MN. Sperry, L. (2003). Handbook of diagnosis and treatment of DSM-IV-TR personality disorders. New York, NY: Routledge, Taylor & Francis Group. Sperry, L., & Carlson J. (1996). Psychopathology & psychotherapy: From DSM-IV diagnosis to treatment (2nd ed.). Washington DC: Taylor & Francis Group. Tillfors, M. (2004). Why do some individuals develop social phobia? A review with emphasis on the neurobiological influences. Nordic Journal of Psychiatry, 58, 267-276. Turner, S. M., Beidel, D. C. & Townsley, R. M. (1992). Social phobia: A comparison of specific and generalized subtypes and avoidant personality disorder. Journal of Abnormal Psychology, 2, 326-331.