Avoidant personality disorder — criteria, differentials and stepped care (MEQ)

(i) Working diagnosis. Avoidant personality disorder (DSM-5-TR): general PD criteria plus ≥4 of 7 features — occupational avoidance of interpersonal contact for fear of criticism, restraint/avoidance of intimacy for fear of shame, preoccupation with rejection, inhibition from inadequacy, self-view as socially inept/inferior, reluctance to take personal risks — present from adolescence, pervasive, impairing. Concurrent social anxiety disorder is justified if marked fear of scrutiny with avoidance/endurance under distress meets duration and impairment thresholds (dual diagnosis common on the continuum). Screen and document major depressive episode given the overdose context. Alcohol misuse as a social safety behaviour is part of the formulation.^[1][2]

(ii) Differentials with discriminators. Pure performance-only SAD without pervasive inadequacy schema (his pattern is broader). Schizoid PD (low desire for relationships vs his stated desire for friends). ASD (developmental social communication differences, restricted/repetitive patterns — history argues against). Dependent PD (submissive care-seeking more than evaluation fear). Major depression as primary (episode course vs lifelong pattern — can be comorbid). Body dysmorphic disorder if appearance-focused. Organic/late-onset change (not fitting age of onset here).^[1][2]

(iii) Risk after overdose. Medical clearance status; intent at the time vs current intent; plan and means; lethality of 12 ibuprofen (often low medical lethality but psychiatric seriousness remains); trigger (critical evaluation); protective factors (called a friend); hopelessness; depression symptoms; alcohol; access to further tablets; isolation; capacity for discharge decisions; collaborative safety plan and means restriction; least-restrictive disposition with rapid follow-up rather than pejorative dismissal.^[1]

(iv) Psychological plan. Alliance-first CBT: shared formulation of inadequacy beliefs → anticipatory anxiety → avoidance/safety behaviours (including pre-event alcohol) → confirmation of fears. Build graded hierarchy (emails → brief meetings → presentations → social gatherings). Behavioural experiments; drop safety behaviours; cognitive restructuring of mind-reading rejection; social skills practice only if true deficits. If global defectiveness schemas dominate, add/switch toward schema therapy — cite Bamelis multicentre RCT effectiveness for PD including Cluster C-relevant samples. Address alcohol with motivational work linked to exposure goals. Measurement (e.g. SPIN/LSAS-style severity + depression scale).^[2][3][5]

(v) Pharmacotherapy principles. No drug treats AVPD as a whole. For comorbid generalised social anxiety and/or depression, first-line SSRI is appropriate alongside CBT. Example: sertraline 50 mg orally once daily, early review (1–2 weeks) for activation and suicidality, titrate toward 50–150 mg daily as tolerated with response review at 6–12 weeks; counsel sexual side effects and discontinuation; limited dispensing post-overdose. Avoid chronic benzodiazepines as the social solution. Stop/review dates and measurement-based care.^[4][5]