Case Study: Mr. X

This was recently posted in the comments, and I am going to approve the comment now. Since this person posted to public Internet comments, I assume they would not have much problem with my posting the comments up as a post. I mean what’s the difference, right?

The individual asked for a differential diagnosis of Schizotypal Personality Disorder and Avoidant Personality Disorder. However, he posted to a post called Differential Diagnosis of Avoidant PD Versus Schizoid PD, so he may want to throw Schizoid PD into the mix also.

I have so many comments to make on this post.

First of all, this individual, who we shall call Mr. X, is not all that unhealthy. I deal with people all the time who are far more unhealthy than this, and sad to say, I myself have even been much worse than this man is for way too long. How long you don’t need to know. Suffice to say, I looked at his comments and wished I had functioned that well when I was in bad shape.

He is able to perform the basic functions of life pretty well. He seems to be able to pack up and move to a new town, which believe it or not, is hard for a lot of adults to do.

He is able to live, survive and function well living alone for a long time now. His place is probably well managed, he probably eats well, etc.  I mean what is  going on inside his front door is pretty healthy.

As far as work goes, I think he is pretty healthy. He ran his own tree-trimming business for years and saved up a lot of money from that. He worked for his father at a drilling business for  several years and functioned well there. He managed to accumulate $500K worth of drilling equipment which he sold, so he is able to make a lot of money in our society. Most people do not have $500K net worth in their 30’s. It’s not that easy to do. He seems to be able to hold jobs, maintain them and function well enough at work to keep at jobs for several years at a time.

Believe it or not, a lot of folks can’t even do that! I’m not even very good at it. I tend to get fired wherever I am because somehow they simply come to dislike me. I’m rarely fired for a good reason because I am a good worker. A few times, I was fired for errors, but they were the sort of jobs where you could make errors even if you were a highly diligent worker. I’ve gotten to the point now where I can survive for up to 1 1/2 years without getting canned,  and that is amazing. I don’t think I am really meant to work with other humans. I probably have to work on my own or resign myself to floating from job to job.

He actually functions a lot better socially than he thinks he does. He is able to make and keep friends. He is able to befriend total strangers. He seems to be a good and loyal friend. In his youth, he was sort of a party animal who hung out all the time and had all sorts of friends. That seems to rule out Avoidant PD right there because no Avoidant PD would have a youth that looked like that and then turn Avoidant in adulthood. With all of the PD’s, we see strong signs of the PD even in  childhood and adolescence.

After all, Axis 2 or PD is meant to describe lifelong patterns. Dramatic behavioral change between adolescence and adulthood would seem to rule out a PD right there because PD’s just don’t look like that. However, he did have some Avoidant traits even back then, and it is perfectly reasonable in this case to diagnose PD traits because I believe that they are there.

He is able to date women, though he does not do so much. He was able to have a four-month relationship which was felt to be “too much,” once again suggesting Avoidant traits. However, a four-month intense relationship is not bad.  Further, he functioned so well in the relationship that the woman fell in love with him, wanted to marry him and even to have his kid. This to me implies that he functions fairly enough well in relationships because if you are a complete relationship retard, the scenario with the woman above really never happens to you.

He wears overalls six days a week, but that’s not pathological. On the other hand, you’re not trying to be the most charismatic man out there when you dress like that. Who are you trying to get? Lady truck drivers?

There is so much more I could say about this case, but for now.

Axis 1: Deferred.

I am going to defer on this for now because to me the main problem is an Axis 2 issue (personality disorder) as opposed to an Axis 1 problem (anxiety, mood or psychotic disorder). Sure, there is some mood and anxiety going on, but it seems to be driven more by the Axis 2 stuff as opposed to being generated on its own, which of course is typical with Axis 2.

Axis 2: Present.

There is definitely an Axis 2 problem here. The person has a longstanding  pattern of behavior that causes him major problems in life that is not related to anything on Axis 1. Instead most if not all of the person’s problems stem from the personality that they have generated for themselves starting in childhood.

There are a lot of problems with other people, and the individual himself seems rather dissatisfied with life. This is because the Axis 2 problem is causing conflicts and difficulties with others and because the Axis 2 problem is getting in the way of him living a happy, fulfilled and self-actualized life. Instead, the Axis 2 problem is causing a life that is lived below the individual’s potential, causing frustration even with the individual himself.

Further and most important of all, the man defends his unhealthy behavior, often fiercely. Obviously this is a core Axis 2 issue. At the end of the statement, he says he may not react well if someone tells him he is doing something wrong. Once again, we see Axis 2.

He person angrily reacts against anyone telling there is anything wrong with him psychologically, that he has an actual DSM disorder, that he needs to see a therapist, and in particular, that he needs medication. Axis 2 again, but he is sort of onto something because he is correct in his belief that he isn’t crazy (Axis 1). Instead, he is Axis 2, and Axis 2 people are not really crazy. Axis 2 people are sick, and the distinction is important. Instead of being crazy, there is something wrong with their souls. They are in a sense sick in their souls, what I call soul-sick. And of course that’s why Axis 2 is so hard to fix. It’s hard to cure a sick soul. How do you fix a problem that involves the individual at their basic core essence?

He refuses to take medication, but once again he is onto something because he’s not crazy in the sense that needs medication (Axis 1). He says he doesn’t need pills and in a way he is correct. Pills often do not work well for Axis 2 anyway.

He spent much of the last year in therapy but did not appear to get a lot done. Once again typical Axis 2. However, he is aware enough to go to therapy apparently on his own, which is excellent for an Axis 2 person. Perhaps because the person has only traits and not a full Axis 2 disorder is what drives him into therapy or even makes him think there is anything wrong with him in the first place. Both are quite uncommon in  Axis 2 people, and the presence of these good signs is an excellent sign that this person can actually make  progress with his Axis 2 stuff.

On the other hand, the last sentence that says he will not take it well if you imply that he is doing anything wrong does not bode well for therapy. Guess what is going to happen to him in therapy? The therapist is going to tell him he is doing things wrong. He will be told this over and over, and oftentimes the therapist will not be very nice about it. If you can’t handle criticism, therapy is a waste of time. However, he did spend most of last year in therapy, so it seems that he sticks out therapy even though he does not like being criticized.

Schizoid PD: Absolutely not.

Schizotypal PD: I have a hard time seeing any symptoms of this. I do not why people think this is the problem.

Avoidant  PD: This is where the problem lies. See detailed explanation below.

There is avoidant behavior littered all through this history starting all the way back in childhood. He gets insulted once, and he won’t talk to the person for a year. Someone criticizes him, and he walks out of the room and out of the person’s life. He doesn’t care about losing a lot of friends, possibly because he would rather push them away anyway. He engages in abrasive and hostile behavior towards friends in order to deliberately drive them away, possibly because he thinks they are getting too close to him. This is a clear case of pushing people away, and pushing people away is classic avoidant behavior.

As noted above, the last sentence here does not bode well and is a classic sign of avoidant behavior. Of course Avoidants don’t take criticism well. That is the core of the whole issue with them.

On the other hand, a true Avoidant PD would probably just get up and walk out of the office as soon as he gets criticized. I had a therapist once (yep I have been on both sides of the fence here) told me that he had had ~7 Avoidants in his time as a therapist.  With every single one of them with not a single exception, as soon as the he criticized the person, the person got a very hurt expression on their face, gathered up their stuff, and walked right out of the office never to return. It’s interesting that he saw the exact same thing in 7 different cases over years, but believe or not, a lot of DSM conditions act like this. It’s almost as if the people with the condition were all reading off the same script, as I call it.

There are also classic signs of low self esteem going all the way back to youth. The symptoms of low self-esteem occur over and over again in this history. Of course, low self-esteem in not in the DSM yet, though I they are probably working on it. Not all psychological problems get a DSM diagnosis. That’s the thing. It is possible to have all sorts of  psychological issues without having a single diagnosable DSM condition. Which of course makes sense as almost all of us are at least a bit unhealthy, are personality disordered in at least a slight way, and are at least a little bit weird and crazy if not perverted on top of that. In other words, humans are very fallible creatures, we are not perfect, and life is full of all sorts of  problems even for the healthiest people.

Low self-esteem might go away with pills, but he is a bit too old for that. Much better reactions are seen with adolescents because the low self-esteem has not cemented itself in yet.

Of all of the issues I have worked with in counseling, the two hardest were Major Depression and low self-esteem. I have tried everything and I cannot seem to get low self esteem to budge. I have seen some folks improve in the issue, but they tend to still have the problem to a lesser extent. For some reason low self esteem seems to get cemented in very hard in the brain such that it is quite difficult to turn around. The best results are seen in childhood and especially adolescence before the personality is fully formed.

Therefore, the diagnosis is:

Axis 1: Deferred, a secondary problem to the Axis 2 problem if it is there at all.

Axis 2: Avoidant PD: Avoidant traits, but does not meet criteria for the full disorder.

Other issues: Chronic low self-esteem dating back decades.

Note: The two problems are feeding into each other in an endless feedback loop, as you  might notice if you read the history carefully. You cannot really defeat one of the two conditions above. The stool is being held up with four legs of the chair. You cannot just take out one leg – you will have to take out two legs to make the chair crash down.


Hi there,

My mother and I have been arguing about this for 15 years or more. I’m 37 and have been sober with the help of AA – off of marijuana daily, hard alcohol weekly, and LSD monthly – sober for more than 11 years now.

I had a girlfriend in high school for 2 or 3 years. I had many friends through early grade school or partying, and we had much fun while also sharing time and feelings…and sometimes we hurt each other. My mother was also very supportive then (and still is, but can also be hurtful on purpose). Pretty normal stuff, but I can remember being avoidant. If someone did one certain thing to piss me off, I might’ve not spoken to them for half a year.

Eventually, at the end if my drug and alcohol abuse, I had managed to alienate or avoid all but one or two drug-using buddies that needed as much of a an illegal head change as me. I was verbally abused as a kid; they had gotten worse.

In sobriety, I’ve had a couple sexual encounters but only one girlfriend, and we lasted maybe 4 months. She was beautiful and looked 30, my age, but she was 42, wanted me to impregnate her, and started suggesting we go to therapy. 4 months was both too little and too much for me.

I also can make friends but I don’t always keep them. I’ve helped people in AA and they’ve helped me, but after all this time, I get pissed if they start to even think about providing help without my asking. Sometimes they think there are things wrong with me, and that’s fine, but if they start basing their decisions on their hack “diagnoses” of me, I might never call them or go to the same meeting as them.

I basically want people to be my friend, and thats it; I’ve been known to want to make people laugh for an hour or more, and this makes me very happy inside. It’s something I was able to do for people when I was young and in high school. If someone gives me a compliment or tells me I’ve accomplished certain things in my life, I shrug it off. It means not much to me; I don’t feel that’s what’s important in life, your accomplishments.

I’ve recently found peace in Zen writing with some practice, studying the writing of Shinryu Sazuki. I don’t talk bad about other people’s beliefs but really find other religions to be silly in practice, and have never believed in a higher power, instead simply practicing that I don’t have the power, any power, not much power – changing the things I can.

I think part of my problem is my mother. If I had a bad week – maybe any week during the past 15 years – she often thought and sometimes said I needed to be diagnosed with a problem, leading to many arguments, some with me even admitting that I had a clinical problem. She keeps pushing the psychiatric drugs, which ill never take (Never; please hear that if you want to reply and actually help).

What’s most hurtful is I create a boundary, yet even when I have a good day (exercise, meditation, doing good things for myself), I can’t trust her to actively cross that boundary and talk about me in a manner, suggesting I can’t cope, that I make mistakes that exhibit avoidant or schizotypal behavior, and generally, her not letting me live my own life…crazy and fucked up or not…

I care that she is more healthy and lives longer and stops having medical issues, but she has been 300 lbs or more – obese – for 20 years or more. I never diagnose her or tell her she is making bad decisions. I don’t give her advice unless she specifically asks. It’s simply a boundary I respect. It’s common decency. I don’t talk about her problems because I learned early on that it was rude and disrespectful.

I could change my perception of her, but its awfully hard when she does this. What worked is I hardly talked with her for a couple years until she did Alanon work of her own avail and started being enjoyable.

Most recently, we’ve gone back to Square One. For 5 years I trimmed trees, netting thousands before 2008. Then I worked as a office person/driller for my father the next 5 years. We’ve gone out of business, so I’m putting a sleeper on my truck while hauling a motorcycle. Me and the two dogs are gonna hoof it. I have some starter money from selling a house back to my parents, so it’s not the craziest.

At the same time, my parents and some other people have decided to reassert the opinion that I have a “condition” and that my decision- making is screwy. I care about their happiness, but they thinking I can’t have a happy life unless I am actively coping with some mental condition and that it deserves pills, it’s crazy to me when they want to relate the opinion on any given day we spend time with each other.

I also recently dropped a class (not a great sign of progress). While moving out of my house and getting rid of nearly every possession I’d collected the past three decades, selling off $500K worth of drilling equipment to pay off a bank and getting over my workaholic father (a perfect example…which is bad… which is another story) and I not succeeding together professionally – I decided to take two journalism classes at the college. I had to drop both.

There I made one friend, quirky, with whom I spent many hours with at the lab portion talking, bullshitting, and working together. I also made a fool of myself with a couple other people. I got in trouble (embarrassing when you’re 30 something) for writing joke, fake stories on the board. Yelled at another student to make people laugh. Was nervous and self-conscious.

I was scared half the time I had done something wrong to somebody, and the dean was gonna come in and kick me off campus or something. I also managed to meet deadlines and publish two stories. It really was too much for me at the time, so I had to drop what I could, school being something that will always be there.

My father was mad when I enrolled that I didn’t advance my AA in BA and chose to go back to the community college, but I just laughed at him and his preferences for me. Journalism has always been a dream of mine and I plan to take more courses. I got a taste for interviewing people and investigating facts and opinions; it looks like another trade for me.

When I’m at my worst, I don’t do anything. I hole up inside of my home and fail to even start my day. I understand this writing here has been about much else, but my problems can be serious. Oftentimes I’m worried about my appearance or cleanliness. Do they know I masturbate too much? are they gonna notice my fingernails are dirty? Worse off, if they knew I was thinking these things, it’d be worse. This thinking leads me to not going out into the world or hard to be around – to where I make no friends, no connections.

Oftentimes a girl working at a store or somewhere will be nice to me. I’m actually kinda good looking…although I wear overalls 6 days a week for the past 5 or 10 years.) I go home and obsess about her, dream about her. Until either way, I cant go back to that store.

I feel disgusting and have bad thoughts. Is she the right one? Am I disgusting? Do they just want my money anyhow? I’m a shitty person? If I just want to get into bed with them, they’ll know, and that’s hurtful. But if I really think she’s smart and we could get married, there’s something wrong with her. She smokes. Something. I’ll find some reason to not go to that store for a year, maybe more.

Am I just an asshole. If I can’t be in a simple moment with people…I am some sort of asshole.

I usually make friends or closer acquaintance with thinkers or people who are quirky. Most often they are 20 years older than me – teachers at my college or mentors in and out of AA but often out. As I start this new adventure, my experience with relationships is two sided; I’ve kept in touch with none of these older or quirky persons, and I’m sick of being around my parents and them taking care of me. I’m leaving town, and I want to get better at leaving town.

One big deal that happened recently is I saved up a bunch of angst about my neighbor (and other things in my life) and yelled at him for 5 minutes so the whole neighborhood could hear me. He was gone, and I was still in my garage scream epithets. We were surprised he didn’t press some kind of charges. But I didn’t directly threaten him so…

Another thing…my mother can do and say things while just sitting in a room that can make me want to strangle myself. I think its part of my condition or general person, and sometimes the way people breathe or move just irks me. I have to leave the room.

Some people bother me, while others don’t. So my solution is simply to only go places and be around people I like. Sometimes this isn’t enough for me – I cant find anywhere or anyone. And this worries my parents. A bad day of mine is reason for me to have medication for them.

When I started going back to meetings 6 months ago, it helped. I find some peace there. Most recently I made a friend then lost him because he wouldn’t call or text me back. I said I forgave him but didn’t really want to try again. I was also worried about what he thought of me, and I hated him for it. Sometimes I think this is normal but it’s also a little obsessive.

When I go to meetings, I feel better. Things that were a big deal become small deals. The problem is the getting there. Its like working out for most; they just need to go, then they feel great. But getting off the couch and to the gym isn’t exactly as important as being able to get along in public situations or meetings, which I definitely have trouble with.

I guess my dilemma is the same as it was 5 years ago. I exhibit a good deal of avoidant or schizotypal behavior but refuse medication. I talked with a therapist for many of the weeks of last year, and he gave me some tools I didn’t have. Mainly they want me to care more about other people or to develop, maintain or exhibit lasting connections with other people.

It takes much exercise and a routine including morning reading to get me to where I can relax and be happy around people besides myself, to where I can appreciate other people or not be scared of what they are thinking of me.

They also say I’m excellent at guitar. Because it’s not a possession but something I can share for free with others. I like playing for them but don’t really care if they like me as a person, and I sometimes put my foot in my mouth, saying or doing things that will drive them away…It’s not always, but I sometimes have no control…And then I just don’t give a shit, it’s freeing that they’ve left me to me. This is the other part of my behavior that’s acceptable to me but not very many others.

Ive tried herbal supplements…and they actually intensify feelings of doom, embarrassment, depression… leading to further or deeper anxiety. Strange, ain’t it?

Sorry for any length above. I value your thoughts, suggestions, experience, and advice outside of medication.

If you want to tell me I’m wrong in any way, I may react very poorly.


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Filed under Mental Illness, Personality Disorders, Psychology, Psychopathology, Psychotherapy

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