A woman brings her 19-year-old daughter to the office due to concerns that she is hypersensitive, depressed, and socially isolated. The mother worries that her daughter is typically withdrawn, has few close friends, and does not date. The mother says, "Although we're very close, a girl her age should be going out and not spending all her free time with her mother. She's also very moody and tends to overreact to the slightest criticism." The patient describes her mood as "unhappy" but has had no change in sleep or appetite. She works as a filing clerk and recently turned down a higher-paying job as a receptionist because, "I prefer to work alone." When questioned about her social isolation, she says, "Who would want to be friends with someone ugly and stupid like me anyway?" Which of the following is the most likely explanation for this patient's behavior?

Question

A woman brings her 19-year-old daughter to the office due to concerns that she is hypersensitive, depressed, and socially isolated.  The mother worries that her daughter is typically withdrawn, has few close friends, and does not date.  The mother says, "Although we're very close, a girl her age should be going out and not spending all her free time with her mother.  She's also very moody and tends to overreact to the slightest criticism."  The patient describes her mood as "unhappy" but has had no change in sleep or appetite.  She works as a filing clerk and recently turned down a higher-paying job as a receptionist because, "I prefer to work alone."  When questioned about her social isolation, she says, "Who would want to be friends with someone ugly and stupid like me anyway?"  Which of the following is the most likely explanation for this patient's behavior?

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11ec25c8_d7e5_2c00_bc81_ed9c833f506b_MD0003_00 This patient's pattern of avoiding social interactions and hypersensitivity to criticism is characteristic of avoidant personality disorder. Personality disorders often manifest in adolescence or early adulthood, are persistent in nature, and are evident in different contexts (such as this patient's work and relationship difficulties). Patients with avoidant personality disorder typically limit their social relationships due to fears of being judged, embarrassed, or rejected. They struggle with feelings of inadequacy and pursue relationships only when they feel assured of uncritical acceptance. Occupational dysfunction due to difficulties interacting with coworkers or turning down promotions due to fear of criticism is common. Although avoidant behaviors may be seen in other personality disorders, the disorders can be differentiated by key features (see table). (Choice B) Individuals with borderline personality disorder are also hypersensitive and preoccupied with fears of rejection and abandonment, but they typically react with anger and manipulative demands. In addition, this patient lacks the pattern typically seen in borderline personality disorder of unstable, intense relationships; impulsivity; and recurrent suicidality or self-harm. (Choice C) Although the patient is dependent on her mother for social activities, this behavior is due to fears of rejection from her peers rather than a need to be cared for. (Choice D) This patient does not have sufficient depressive symptoms to diagnose persistent depressive disorder (dysthymia). Her unhappiness is related to her social isolation and better explained by her avoidant personality disorder. (Choice E) Individuals with schizoid personality disorder are loners who do not desire social acceptance. The patient's reply to the physician's inquiry suggests that she is unhappy with her social isolation and desires relationships but fears being humiliated or rejected. Educational objective: Avoidant personality disorder is characterized by a persistent pattern of social avoidance, feelings of inadequacy, and hypersensitivity to rejection beginning in adolescence or early adulthood. References: Personality functioning in patients with avoidant personality disorder and social phobia. (http://www.ncbi.nlm.nih.gov/pubmed/23786266) Avoidant personality disorder: a current review. (http://www.ncbi.nlm.nih.gov/pubmed/26830887)

A Woman Brings Her 19-Year-Old Daughter to the Office Due