Psychological interventions for avoidant personality disorder

(Protocol)

Ahmed U, Gibbon S, Jones H, Huband N, Ferriter M, Völlm BA, Stoffers JM, Lieb K, Dennis
JA, Duggan C

This is a reprint of a Cochrane protocol, prepared and maintained by The Cochrane Collaboration and published in The Cochrane
Library 2012, Issue 1
http://www.thecochranelibrary.com

Psychological interventions for avoidant personality disorder (Protocol)

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Psychological interventions for avoidant personality disorder (Protocol) i

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Protocol]

Psychological interventions for avoidant personality disorder

Uzair Ahmed1 , Simon Gibbon2 , Hannah Jones3 , Nick Huband4 , Michael Ferriter5 , Birgit A Völlm4 , Jutta M Stoffers6,7 , Klaus Lieb
7
, Jane A Dennis8 , Conor Duggan4

1 North Yorkshire
and York PCT, York, UK. 2 St Andrew’s Healthcare, Northampton, UK. 3 Cochrane Schizophrenia Group, University
of Nottingham, Nottingham, UK. 4 Forensic Mental Health, Institute of Mental Health, University of Nottingham Innovation Park,
Nottingham, UK. 5 Forensic Division, Nottinghamshire Healthcare NHS Trust, Woodbeck, UK. 6 Department of Psychiatry and
Psychotherapy, University Medical Center Freiburg, Freiburg, Germany. 7 Department of Psychiatry and Psychotherapy, University
Medical Center Mainz, Mainz, Germany. 8 c/o Developmental, Psychosocial and Learning Problems Group, Queen’s University, Belfast,
UK

Contact address: Michael Ferriter, Forensic Division, Nottinghamshire Healthcare NHS Trust, The Clair Chilvers Centre, Rampton
Hospital, Woodbeck, Nottinghamshire, DN22 0PD, UK. Michael.Ferriter@nottshc.nhs.uk.

Editorial group: Cochrane Developmental, Psychosocial and Learning Problems Group.

Publication status and date: New, published in Issue 1, 2012.

Citation: Ahmed U, Gibbon S, Jones H, Huband N, Ferriter M, Völlm BA, Stoffers JM, Lieb K, Dennis JA, Duggan C. Psychological
interventions for avoidant personality disorder. Cochrane Database of Systematic Reviews 2012, Issue 1. Art. No.: CD009549. DOI:
10.1002/14651858.CD009549.

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT

This is the protocol for a review and there is no abstract. The objectives are as follows:

This review aims to evaluate the potential beneficial and adverse effects of psychological interventions for people with avoidant
personality disorder.

BACKGROUND hood and present in a variety of contexts, as indicated by four (or

more) of the following:
(1) avoids occupational activities that involve significant interper-
sonal contact because of fears of criticism, disapproval or rejec-
Description of the condition tion.
(2) is unwilling to get involved with people unless certain of being
A personality disorder is “an enduring pattern of inner experience
liked.
and behaviour that deviates markedly from the expectations of the
(3) shows restraint within intimate relationships because of the
person’s culture, is pervasive and inflexible, has an onset in adoles-
fear of being shamed or ridiculed.
cence or early adulthood, is stable over time and leads to distress or
(4) is preoccupied with being criticised or rejected in social situa-
impairment”, according to the Diagnostic and Statistical Manual
tions.
of Mental Disorders (DSM-IV-TR) (APA 2000). Avoidant per-
(5) is inhibited in new interpersonal situations because of feelings
sonality disorder is characterised by DSM-IV-TR (APA 2000) as “a
of inadequacy.
pervasive pattern of social inhibition, feelings of inadequacy, and
(6) views self as socially inept, personally unappealing, or inferior
hypersensitivity to negative evaluation, beginning in early adult-
Psychological interventions for avoidant personality disorder (Protocol) 1
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
to others.
(7) is unusually reluctant to take personal risks or to engage in any
new activities because they may prove embarrassing.”
DSM-IV-TR also comments on the overlap between avoidant per-
sonality disorder and social phobia (generalised type) and suggest
that they may be alternative conceptualisations of the same or sim-
ilar condition. Interestingly, Mendlowicz 2006 noted an increase
in papers published on social phobia from 1973 to 2001, with
a decrease in publications on avoidant personality disorder over
the same period. However, it is also worth noting that the current
draft of the fifth edition of the Diagnostic and Statistical Manual
of Mental Disorders (DSM-V), which will be published in 2013,
recommends retaining social phobia as a diagnosis and reformu-
lating avoidant personality disorder as avoidant type (APA 2010).
The International Classification of Mental and Behavioural Dis-
orders (ICD-10) (World Health Organization 1992) refers to this
disorder as “anxious (avoidant) personality disorder” and describes
much the same characteristics as DSM-IV-TR but requires only
three of the behaviours to be present in order to qualify for a di-
agnosis.
Avoidant personality traits are common but a diagnosis of avoidant
personality disorder is only made when these are inflexible, mal-
adaptive and persist to an extent that causes significant impair-
ment or distress to the individual (APA 2000).
Togersen 2001 found avoidant personality disorder to be the most
common personality disorder in a large community-based sample,
with prevalence rates of 5%. In clinical samples, the disorder is
thought to be present in about 10% of outpatients (APA 2000).
Coid 2003 summarised the findings of various community sur-
veys and reported prevalence ranges from 0.8% to 5% with high
comorbidity. However, subsequently, Coid 2006 found a much
lower prevalence rate of 0.8% in a household survey of 626 par-
ticipants.
The aetiology of avoidant personality disorder is unknown, but re-
search suggests there are a number of biological and psychological
factors (Dalrymple 2007). Biological factors include neurochem-
ical abnormalities such as serotonergic system deficits (Cloninger
1986), familial and genetic transmission (Cloninger 1986) and
inborn temperament, for example, a tendency to retreat from un-
familiar situations (Kagan 1989). Psychological factors have also
been found to play their part in the development and maintenance
of avoidant personality disorder. Examples of this would include
childhood experiences (for example, pathological parenting such
as parental rejection (Beck 1990)); cognitive biases similar to those
seen in social anxiety disorder (for example, memory and interpre-
tation biases) (Hirsch 2004), and social skills deficits (for example,
avoidance of a range of social situations).
Kaplan 2005 found avoidant personality disorder to be associ-
ated with severe occupational and social impairment. In clinical
samples, avoidant personality disorder is often comorbid with de-
pendant personality disorder, anxiety disorders (especially social
phobia, generalised type) and depressive episodes (Herbert 1992;
Psychological interventions for avoidant personality disorder (Protocol)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Holt 1992; Turner 1992). Zanni 2007 found personality disorder
symptoms may change with age; some symptoms can become less
prominent while others become worse.
The prognosis for avoidant personality disorder is quite poor as
individual habits and attitudes are often pervasive and ingrained,
with many lacking the support and encouragement they need to
improve their lifestyle (Millon 1996). Skodol 2005 and Newton-
Howes 2006 found a personality disorder that co-occurs with an
Axis-I disorder may have a negative impact on the outcome of the
latter. Percudani 2002 found a higher probability of these patients
withdrawing from treatment. Other studies suggest individuals
with personality disorders are less likely to make contact with
psychiatric services compared with those with other conditions
such as schizophrenia or depression (Andrews 2001). They are
often not recognised by professionals and they do not seek help
(Herbert 2004).
Description of the intervention
Psychological therapies encompass a wide range of interventions
(Bateman 2004) including psychoanalytic psychotherapy, cogni-
tive therapy, therapeutic communities and nidotherapy. The gen-
eral goal of treatment in avoidant personality disorder is improve-
ment of self-esteem and confidence. As the individuals’ self-con-
fidence and social skills improve, they will become more resilient
to potential or real criticism by others.
It is important to consider all relevant studies without restriction
on the type of psychological therapy and to consider psychological
interventions where drugs are also given as an adjunctive inter-
vention. Individual and group therapeutic interventions may be
used, although the nature of avoidant personality disorder itself
may make group therapy less common.
How the intervention might work
Psychoanalytic therapies (which include dynamic psychotherapy,
transference-focused psychotherapy, mentalisation and group psy-
chotherapy) aim to help the patient understand and reflect on his
inner mental processes and make links between his past and his
current difficulties.
Cognitive analytic therapy (CAT) is a brief psychological therapy
utilising ideas from psychodynamic psychotherapy, cognitive ther-
apy and cognitive psychology (Denman 2001). Current coping
strategies are looked at in detail and are adapted to bring about
change through the client’s strengths, resources and tools.
Treatments based on cognitive behavioural therapy (CBT) place
emphasis on encouraging the patient to challenge their core beliefs.
A review of the evidence for this form of intervention concluded
that “the overall evidence in favour of cognitive behavioural ther-
apy in the treatment of personality disorder is therefore relatively
slim, with much of the evidence coming from one research group,
2
but it has involved more patients than any other form of treat-
ment” (Bateman 2004).
Dialectical behavioural therapy (DBT) is a complex psychological
intervention that was developed using some of the principles of
CBT (Linehan 1993) and may help change behaviour by improv-
ing skills and the ability to contain difficult feelings. It is currently
popular, but the evidence for its efficacy is less clear with some
reviewers considering that its only proven benefit appears to be in
the reduction of self-harm episodes (Bateman 2004).
Therapeutic community treatments involve participants (also
known as residents) not only having therapy together but also
working and living together in a shared, therapeutic environment.
This provides them with an opportunity to “explore intrapsychic
and interpersonal problems and find more constructive ways of
dealing with distress” (Campling 2001). Therapeutic community
treatment is the only single treatment modality for severe personal-
ity disorder that has been subject to a meta-analysis of randomised
controlled trials. This demonstrated the effectiveness of therapeu-
tic community treatment (Lees 1999), but specific personality dis-
orders were not identified.
Nidotherapy is a formalised, planned method for achieving en-
vironmental change to minimise the effect of the disorder both
upon those with the diagnosis and those around them. The ef-
fectiveness of this treatment has not yet been established. Unlike
most other therapies, it aims to fit the immediate environment to
the individual rather than change the individual to cope in the
existing environment (Tyrer 2007). Whilst the eventual outcome
of nidotherapy is environmental manipulation, it may be regarded
as a psychological intervention in that it relies upon first devel-
oping a psychological understanding of the person’s strengths and
difficulties. The psychological formulation leads to goal setting,
from which flows the necessary changes in the physical and social
environment (Tyrer 2005).
Why it is important to do this review
Despite avoidant personality disorder being one of the most com-
mon personality disorders and having considerable impact on in-
dividuals and their families, it is interesting that relatively few stud-
ies have examined the treatment of individuals specifically selected
for avoidant personality disorder (Alden 2002). Evidence for the
efficacy of psychodynamic psychotherapy for personality disorders
comes from Piper 1993, Winston 1994 and Bateman 2001. One
study by Emmelkamp 2006 found CBT to be more effective than
Brief Dynamic Therapy (BDT) for treating avoidant personality
disorder, although methodological shortcomings with this study
have been found (Leichsenring 2007). There has been an increased
interest in developing and evaluating psychological treatments for
personality disorders in recent years, suggesting that a systematic
review is now timely to assess the quality of available evidence.
Psychological interventions for avoidant personality disorder (Protocol)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
OBJECTIVES
This review aims to evaluate the potential beneficial and adverse
effects of psychological interventions for people with avoidant per-
sonality disorder.
METHODS
Criteria for considering studies for this review
Types of studies
Controlled trials in which participants have been randomly allo-
cated to an experimental group and a control group, where the
control condition is either treatment as usual, waiting list or no
treatment. We will include all relevant randomised controlled tri-
als with or without blinding of the assessors.
Types of participants
Men or women 18 years or over with a diagnosis of avoidant
personality disorder defined by any operational criteria such as
DSM-IV. We will include studies of people diagnosed with comor-
bid personality disorders or other mental health problems other
than the major functional mental illnesses (that is schizophrenia,
schizoaffective disorder or bipolar disorder). The decision to ex-
clude persons with comorbid major functional illness is based on
the rationale that the presence of such disorders (and the possible
confounding effects of any associated management or treatment)
might obscure whatever other psychopathology (including per-
sonality disorder) might be present.
Types of interventions
We will include studies of individual and group psychological in-
terventions. Psychological interventions will be subclassified into
single modality and complex psychological interventions. Sin-
gle modality psychological interventions are those that only in-
volve one specific type of intervention. Complex psychological
interventions are those that involve more than one modality of
treatment, for example, group therapy plus individual therapy
(Campbell 2000). We will include studies of psychological inter-
ventions where medication is given as an adjunctive intervention,
but will report any studies where the comparison is between a psy-
chological and a pharmacological intervention separately. We will
not include studies comparing two or more different therapeutic
modality groups but without a control group.
3
Types of outcome measures
Primary and secondary outcomes are listed below in terms of single
constructs. We anticipate that a range of outcome measures will
have been used in the studies included in the review, for example,
avoidance may be measured by self report scales or by an external
observer. Whilst we acknowledge that the nature of avoidant per-
sonality disorder can lead to difficulty in long-term follow-up, we
will report relevant outcomes without restriction on the period of
follow-up.
Primary outcomes
• Avoidance symptoms: improvement in avoidant behaviour
as measured on validated clinical scales such as the Structured
Clinical Interview for DSM-IV Axis II Personality Disorders
(SCID-II) (First 1997) or the Structured Interview for DSM-IV
Personality (SIDP-IV) (Pfohl 1997), or self report measures such
as the NEO Personality Inventory (NEO-PI-R)/NEO Five-
Factor Inventory (NEO-FFI) (Costa 1992) or Millon Clinical
Multiaxial Inventory-III (MCMI-III) (Millon 1994).
• Global state/functioning: as measured through
improvement on the Global Assessment of Functioning numeric
scale (GAF) (APA 2000), Clinical Global Impression of Severity
scale (CGI-S) (Guy 1976), Symptom Checklist-90 (SCL-90R)
(Derogatis 1994) or similar validated scales.
• Social functioning: as measured through improvement on
the Social Adjustment Scale (SAS-SR) (Weissman 1976), the
Social Functioning Questionnaire (SFQ) (Tyrer 2005) or similar
validated scales.
• Adverse events: incidence of overall adverse events and of
the three most common adverse events; dichotomous outcome,
measured as numbers reporting.
Secondary outcomes
• Quality of life: self-reported improvement in overall quality
of life measured through improvement in scores on the European
Quality of Life instrument (EuroQol) (EuroQoL 1990), SF36
(Ware 1993) or similar validated scales.
• Engagement with services: health-seeking engagement with
services measured though improvement on the Service
Engagement Scale (SES) (Tait 2002) or similar validated scales.
• Anxiety symptoms: improvement in anxiety symptoms
measured on the State-Trait Anxiety Inventory (STAI) (Spielberg
1983) or similar validated scales.
• Depressive symptoms: improvement in depressive
symptoms measured on the Hamilton Depression Rating Scale
(HAMD) (Hamilton 1969), the Beck Depression Inventory
(BDI) (Beck 1961) or similar validated scales.
• Satisfaction with treatment: measured through
improvement in scores on the Client Satisfaction Questionnaire
(CSQ-8) (Attkisson 1982) or similar validated scales.
Psychological interventions for avoidant personality disorder (Protocol)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
• Leaving the study early: measured as a proportion of
participants discontinuing treatment from the point of
randomisation.
• Employment status: measured as number of days in
employment over the assessment period.
Search methods for identification of studies
Electronic searches
We will search the electronic databases listed below.
• Cochrane Central Register of Controlled Trials
(CENTRAL), part of the Cochrane Library
• MEDLINE
• EMBASE
• CINAHL
• PsycINFO
• ASSIA
• BIOSIS
• Dissertation Abstracts
• National Criminal Justice Reference Service Abstracts
• Science Citation Index (SCI)
• Social Sciences Citation Index (SSCI)
• Sociological Abstracts
• ZETOC (Conference search)
• metaRegister of Controlled Trials
We will base the searches on the following MEDLINE search strat-
egy, which includes the Cochrane highly sensitive search strategy
for identifying randomised trials (Lefebvre 2008). The strategy
includes search terms for all types of personality disorder as this
is one of a series of PD reviews. We will modify the search terms
and syntax as necessary for other databases.
1 exp Personality Disorders/
2 (moral adj2 insanity).tw.
3 (DSM and (axis and II)).tw.
4 (ICD and (F60 or F61 or F62)).tw.
5 ((odd$ or eccentric$ or dramatic$ or emotional$ or anxious$ or
fearful$) adj5 cluster$).tw.
6 (“Cluster A” or “Cluster B” or “Cluster C”).tw.
7 ((aggressiv$ or anxious$ or borderline$ or dependent$ or emo-
tional$ or passiv$ or unstable) adj5 personalit$).tw.
8 (anankastic$ or asocial$ or avoidant$ or antisocial$ or anti-
social$ or compulsiv$ or dissocial$ or histrionic$ or narciss$ or
obsessiv$ or paranoi$ or psychopath$ or sadist$ or schizoid$ or
schizotyp$ or sociopath$).tw.
9 (personalit$ adj5 disorder$).tw.
10 character disorder$.tw.
11 (anal$ adj (personalit$ or character$ or retentiv$)).tw.
12 or/1-11
4
13 randomized controlled trial.pt.
14 controlled clinical trial.pt.
15 randomi#ed.ab.
16 placebo.ab.
17 drug therapy.fs.
18 randomly.ab.
19 trial.ab.
20 groups.ab.
21 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20
22 exp animals/ not humans.sh.
23 21 not 22
24 12 and 23
Searching other resources
We will search the reference lists of included and excluded studies
for additional relevant trials. We will also examine bibliographies of
systematic review articles published in the last five years to identify
relevant studies. We will also contact authors of relevant studies to
enquire about other sources of information and the first author of
each included study for information regarding unpublished data.
Data collection and analysis
Selection of studies
This review is one of a series of reviews about personality disorders.
We will carry out the selection of studies out in two stages. Four
members of the review team (JS, NH, JD, MF) will read the titles
and abstracts independently to identify all studies carried out with
participants with personality disorder, regardless of any specific
personality disorder(s) diagnosed. They will then independently
assess full copies of studies identified against the inclusion criteria
for this review. We will identify not only trials with participants
diagnosed with avoidant personality disorder but also trials with
participants having a mix of personality disorders for which data
on a subgroup with avoidant personality disorder may be available.
We will resolve uncertainties concerning the appropriateness of
studies for inclusion in the review through consultation with a
third author (CD). Authors will not be blinded to the name(s) of
the study author(s), their institution(s) or publication sources at
any stage of the review.
Data extraction and management
UA, HJ and MF will independently extract data using a data ex-
traction form. We will enter data into Review Manager 5.1 soft-
ware (RevMan) (Review Manager 2011). Where data are not avail-
able in the published trial reports, we will contact the authors and
ask them to supply the missing information.
Psychological interventions for avoidant personality disorder (Protocol)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Assessment of risk of bias in included studies
For each included study UA, HJ and MF will independently com-
plete the Cochrane Collaboration’s tool for assessing risk of bias
(Higgins 2008, section 8.5.1). Any disagreement will be resolved
through consultation with UA. We will assess the degree to which:
• the allocation sequence was adequately generated (’sequence gen-
eration’);
• the allocation was adequately concealed (’allocation conceal-
ment’);
• knowledge of the allocated interventions was adequately pre-
vented during the study (’blinding’);
• incomplete outcome data were adequately addressed;
• reports of the study were free of suggestion of selective outcome
reporting; and
• the study was apparently free of other problems that could put
it at high risk of bias.
We will allocate each domain one of three possible categories for
each of the included studies: low risk of bias, high risk of bias and
unclear risk of bias where the risk of bias is uncertain or unknown.
Measures of treatment effect
Where different outcome measures of the same construct are re-
ported, we will use the standardised mean difference (SMD) to
provide an overall estimate of effect size for that construct.
For dichotomous (binary) data, we will use the odds ratio (OR)
with a 95% confidence interval (CI) to summarise results within
each study. The odds ratio is chosen because it has statistical ad-
vantages relating to its sampling distribution and its suitability for
modelling, and is a relative measure so can be used to combine
studies. For continuous data, such as the measurement of impul-
siveness and aggression on a scale, we will compare the mean score
for each outcome, as determined by a standardised tool, between
the two groups to give a mean difference (MD), again with a 95%
confidence interval. Where possible, we will make these compar-
isons at specific follow-up periods: (1) within the first month; (2)
between one and six months, and (3) between six and 12 months.
Where possible, we will present endpoint data; where both end-
point and change data are available for the same outcomes, then
we will report only the former.
We will report continuous data that are skewed in a separate table
and we will not calculate treatment effect sizes to minimise the risk
of applying parametric statistics to data that depart significantly
from a normal distribution. We will define skewedness as occurring
when, for a scale or measure with positive values and a minimum
value of zero, the mean is less than twice the standard deviation
(Altman 1996). We will use the mean difference (MD) where the
same outcome measures are reported in more than one study. We
will use the standardised mean difference (SMD) where different
outcome measures of the same construct are reported. If studies
are considered to have more than one eligible outcome for a forest
5
plot, we would select a single outcome based on expert advice,
principally the most commonly used with the highest validity.
Unit of analysis issues
Cluster-randomised trials
Where trials have used clustered randomisation, we anticipate that
study investigators would have presented their results after appro-
priately controlling for clustering effects (robust standard errors
or hierarchical linear models). If it is unclear whether a cluster-
randomised trial has used appropriate controls for clustering, we
will contact the study investigators for further information. Where
appropriate controls were not used, we will request individual par-
ticipant data and re-analyse data using multilevel models that con-
trol for clustering. Following this, we will meta-analyse effect sizes
and standard errors in RevMan (Review Manager 2011) using the
generic inverse method (Higgins 2008). If appropriate controls
were not used and individual participant data are not available, we
will seek statistical guidance from the Cochrane Statistical Meth-
ods Group and external experts as to which method to apply to
the published results in attempt to control for clustering. If there
is insufficient information to control for clustering, we will enter
outcome data into RevMan using individuals as the units of anal-
ysis, and then we will use sensitivity analysis to assess the potential
biasing effects of inadequately controlled clustered trials (Donner
2001).
Cross-over trials
It is unlikely for cross-over trials to be used for a psychological in-
tervention due to issues concerning a ’washout’ period. However,
if any cross-over trials are found and we conduct a meta-analysis
combining the results of cross-over trials, we will use the inverse
variance methods recommended by Elbourne 2002. Where data
presented from a cross-over trial are restricted (and more informa-
tion is not available from the original investigators), we will use
the presented data within the first phase only, up to the point of
cross-over.
Multi-arm trials
We will include all eligible outcome measures for all trial arms in
this review. Where there are more than two arms of the trial that
meet the inclusion criteria, two or more intervention arms and/or
two or more control group arms, there are a number approaches
that can be used. These include combining arms to create one sin-
gle pair-wise comparison; selecting one pair for comparison only;
splitting the ’shared’ group into two or more groups to provide
two or more comparisons; including two or more correlated com-
parisons, or undertaking a multiple treatment meta-analysis. In
the event of a multi-arm trial meeting our inclusion criteria, we
Psychological interventions for avoidant personality disorder (Protocol)
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
will seek statistical advice on which of these options is the most
appropriate for the study.
Dealing with missing data
We will contact the original investigators to request any missing
data and information on whether or not it can be assumed to be
’missing at random’.
For dichotomous data, we will report missing data and dropouts
for each included study and will report the number of participants
who are included in the final analysis as a proportion of all partici-
pants in each study. We will provide reasons for missing data in the
narrative summary and will assess the extent to which the results
of the review could be altered by the missing data by, for exam-
ple, a sensitivity analysis based on consideration of ’best-case’ and
’worst-case’ scenarios (Gamble 2005). Here, the best-case scenario
is that where all participants with missing outcomes in the exper-
imental condition had good outcomes and all those with missing
outcomes in the control condition had poor outcomes, and the
worst-case scenario is the converse (Higgins 2008, section 16.2.2).
For missing continuous data, we will provide a qualitative sum-
mary. The standard deviations of the outcome measures should
be reported for each group in each trial. If these are not given, we
will impute standard deviations using relevant data (for example,
standard deviations or correlation coefficients) from other, similar
studies (Follmann 1992) but only if, after seeking statistical ad-
vice, to do so is deemed practical and appropriate. Where missing
data might be assumed to be missing at random then it may be
appropriate to analyse only the available data. Where it may not be
possible to assume this, i.e. the data are ’not missing at random’,
it might be possible to impute missing data with replacement val-
ues, for example, last observation carried forward. We would only
use other methods of imputing missing values with uncertainty or
using statistical models on the advice and with the assistance of a
statistician.
Assessment of heterogeneity
We will assess the extent of between-trial differences and the con-
sistency of results of any meta-analysis in three ways: by visual
inspection of the forest plots; by performing the Chi2 test of het-
erogeneity (where a significance level less than 0.10 will be in-
terpreted as evidence of heterogeneity) and by examining the I2
statistic (Higgins 2008; section 9.5.2). The I2 statistic describes
approximately the proportion of variation in point estimates due
to heterogeneity rather than sampling error. We will consider I2
values of less than 40% as where heterogeneity may not be im-
portant; values in the range 30% to 60% may represent moderate
heterogeneity; values in the range 50% to 90% may represent sub-
stantial heterogeneity, and 75% to 100% represents considerable
heterogeneity.
We will attempt to identify any significant determinants of het-
erogeneity categorised as moderate or high. We cannot state in
6
advance what our preferred method of dealing with heterogeneity,
if present, will be as this will be contingent on the data. However,
we will first check that the data were correctly entered. There are
a number of methods that can be used for handling heterogeneity
and these include the following. The studies can be examined to
explore the reason for heterogeneity but this is not recommended
where there are few studies. A random-effects model could be used.
Where a study paper is an outlier, sensitivity analysis can be carried
out with and without the study. Other strategies include ignoring
the heterogeneity, not performing a meta-analysis and changing
the effect measure. We will seek statistical advice before using any
of these methods.
Assessment of reporting biases
We will draw funnel plots (effect size versus standard error) to
assess publication bias if sufficient studies are found. Asymmetry
of the plots may indicate publication bias, although they may also
represent a true relationship between trial size and effect size. If
such a relationship is identified, we will further examine the clinical
diversity of the studies as a possible explanation (Egger 1997).
Data synthesis
We will undertake a quantitative synthesis of the data using both
fixed-effect and random-effects models. Meta-analyses may be
conducted to combine comparable outcome measures across stud-
ies. In carrying out meta-analysis, the weight given to each study
will be the inverse of the variance so that the more precise estimates
(from larger studies with more events) are given more weight. We
will use random-effects models because studies may include some-
what different treatments or populations. We will group outcome
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∗
Indicates the major publication for the study

HISTORY
Protocol first published: Issue 1, 2012

CONTRIBUTIONS OF AUTHORS
UA and HJ prepared the protocol. JD, MF, NH and JS will examine and select the citations and CD will provide adjudication. JD,
MF, SG and BV will examine and select the papers and CD will adjudicate. UA, HJ and MF will extract the data, complete risk of bias
tables and enter the data. UA, SG, HJ, CD, KL and MF will write the discussion.

DECLARATIONS OF INTEREST

• Uzair Ahmed - none known.

• Simon Gibbon - none known.
• Hannah Jones - none known.
• Nick Huband - investigator in a completed randomised controlled trial of social problem-solving therapy plus psychoeducation
for people with personality disorder (Huband 2007).
• Michael Ferriter - none known.
• Birgit A Völlm - none known.
• Jutta Stoffers - none known.
• Klaus Lieb - Chair, Department of Psychiatry and Psychotherapy, University Medical Center Mainz; advisor to a planned
randomised controlled trial of Inpatient Schema therapy in patients with personality disorders.
• Jane Dennis - none known.
• Conor Duggan - Chair, UK National Institute of Clinical Excellence Committee on antisocial personality disorder; advisor to a
current randomised controlled trial of schema-focused therapy at Ashworth Special Hospital, UK; investigator in a completed
randomised controlled trial of social problem-solving therapy plus psychoeducation for people with personality disorder (Huband
2007).

Psychological interventions for avoidant personality disorder (Protocol) 10

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
SOURCES OF SUPPORT

Internal sources
• Nottinghamshire Healthcare NHS Trust, UK.
• German Federal Ministry of Education and Research. Grant no. 01KG0812, Germany.

External sources
• NHS Cochrane Collaboration Programme Grant Scheme, UK.

Psychological interventions for avoidant personality disorder (Protocol) 11

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.