Stability or instability in avoidant personality disorder:Mode fluctuations within schema therapy sessions

Background and objectives Avoidant personality disorder (APD) is among the most prevalent personality disorders, but has received relatively little empirical attention. This study aims to characterize the frequency, intensity, and fluctuation patterns seen in the modes (self-states) of APD clients over the course of schema therapy (ST), a psychotherapy approach developed especially for personality disorders. Method The newly-developed client mode rating scale (CMRS) was used to code every 5-min segment (n = 645) of 60 ST sessions. Each segment was coded by two independent raters, achieving adequate reliability. Results The avoidant/detached mode was present in 74% of therapy segments and was the most intense and unstable mode; the vulnerable child mode was present in 58% of segments and was the second most intense and unstable mode; the dysfunctional parent mode was present in 40% of segments, and was the third most intense and unstable mode; the over-compensator, compliant-surrenderer, and healthy adult modes were present in around 33% of segments, but the healthy adult mode was significantly more stable than all others. Limitations Although 645 segments were coded, they were drawn from only 15 APD clients with no control group. Further studies are needed to established specificity to APD. Conclusions This study demonstrates the utility of the mode concept as a lexicon for capturing personality states and their instability. It highlights the use of in-session segment-by-segment ratings to assess client change within psychotherapy. Although DSM5 fails to address instability as a criterion for avoidant personality disorder, the APD clients in the current study were characterized by considerable mode instability.