Avoidant individuals seek to retreat from the interactions in which they are placed. There are patients who develop a pattern of being completely compliant, saying very little, making no demands but simply not getting better. I have always referred to these as “invisible patients:” they make no commotion, they make no waves, they make few demands and they just languish in care. They do not seek to mobilize; they do not seek closure. They do not reach out to physicians or nurses and are largely quiet when being examined, referred or treated.
There are two personality disorders that account for this type of response:
a. Schizoid Personality Disorder: represents a pattern of detachment from relationship and a restricted range of emotional expression. The individual prefers solitary activities, lacks close friends, does not seek to be part of a family, appears indifferent to both praise and criticism and seems aloof, cold and remote with little emotional variability.
b. The Avoidant Personality Disorder is characterized by fears of criticism and disapproval. The person mobilizes all resources to insure that they are not rejected and are preoccupied with the fears/thoughts of rejection. People with AvPD often consider themselves to be socially inept or personally unappealing, and avoid social interaction for fear of being ridiculed, humiliated, rejected or disliked.
Both of these personalities markedly impact the ability to emotionally reach the patient in order to understand their pain complaints, their fears and their resistance to mobilize.
In both, the individual may have had a marginal adaptation to the workforce and found a job which protected them from the anxiety of normal human interaction. If they are removed from that setting, even temporarily, they may feel that they cannot return (even though the fear is irrational and may be based upon their own social monitoring).
Social monitoring occurs when an individual ceases to be spontaneous, and, instead, is continually observing his/her own behavior and the ways in which others respond.
To work with these individuals takes an understanding of their limitations and the fears that keep them locked away from spontaneous interaction.