| Avoidant personality disorder | |
|---|---|
| Synonyms | Anxious personality disorder |
| Specialty | Psychiatry |
Avoidant personality disorder (AvPD) is a Cluster C personality disorder. Those affected display a pattern of severe social anxiety, social inhibition, feelings of inadequacy and inferiority, extreme sensitivity to negative evaluation and rejection, and avoidance of social interaction despite a strong desire for intimacy. The behavior is usually noticed by early adulthood and occurs in most situations.
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. They generally avoid becoming involved with others unless they are certain they will be liked. As the name suggests, the main coping mechanism of those with AvPD is avoidance of feared stimuli. Childhood emotional neglect (in particular, the rejection of a child by one or both parents) and peer group rejection are associated with an increased risk for its development; however, it is possible for AvPD to occur without any notable history of abuse or neglect.
Some researchers have theorized certain cases of AvPD may occur when individuals with innately high sensory processing sensitivity (characterized by deeper processing of physical and emotional stimuli, alongside high levels of empathy) are raised in abusive ' negligent ' or otherwise dysfunctional environments, which inhibits their ability to form secure bonds with others.
Signs and symptoms
Avoidant
individuals often choose jobs of isolation so that they do not have to
interact with the public regularly, due to their anxiety and fear of
embarrassing themselves in front of others. Some with this disorder may
fantasize about idealized, accepting, and affectionate relationships,
due to their desire to belong. Individuals with the disorder tend to
describe themselves as uneasy ' anxious ' lonely ' unwanted ' and
isolated from others.
They often feel themselves unworthy of the relationships they desire,
so they shame themselves from ever attempting to begin them.
People with AvPD are preoccupied with their own shortcomings and
form relationships with others only if they believe they will not be
rejected. Loss and social rejection are so painful that these
individuals will choose to be alone rather than risk trying to connect
with others. They, often, view themselves with contempt,
while showing an increased inability to identify traits within
themselves that are generally considered as positive within their
societies.
- Extreme shyness or anxiety in social situations, though the person feels a strong desire for close relationships
- Heightened attachment-related anxiety, which may include a fear of abandonment
- Substance abuse and/or dependence
Comorbidity
AvPD is reported to be especially prevalent in people with anxiety disorders, although estimates of comorbidity
vary widely due to differences in (among others) diagnostic
instruments. Research suggests that approximately 10–50% of people who
have panic disorder with agoraphobia
have avoidant personality disorder, as well as about 20–40% of people
who have social anxiety disorder. In addition to this, AvPD is more
prevalent in people who have comorbid social anxiety disorder and
generalised anxiety disorder than in those who have only one of the
aforementioned conditions.
Some studies report prevalence rates of up to 45% among people with generalized anxiety disorder and up to 56% of those with obsessive-compulsive disorder. Posttraumatic stress disorder is also commonly comorbid with avoidant personality disorder.
Avoidants are prone to self-loathing and, in certain cases, self-harm.
In particular, avoidants who have comorbid PTSD have the highest rates
of engagement in self-harming behavior, outweighing, even, those with borderline personality disorder (with or without PTSD). Substance use disorders are, also, common in individuals with AvPD—particularly in regards to alcohol, benzodiazepines and heroin—and may significantly affect a patient's prognosis.
Earlier theorists proposed a personality disorder with a combination of features from borderline personality disorder and avoidant personality disorder, called "avoidant-borderline mixed personality" (AvPD/BPD).
Causes
Causes of AvPD are not clearly defined, but appear to be influenced by a combination of social, genetic, and psychological factors. The disorder may be related to temperamental factors that are inherited.
Specifically, various anxiety disorders in childhood and adolescence
have been associated with a temperament characterized by behavioral
inhibition, including features of being shy, fearful, and withdrawn in
new situations. These inherited characteristics may give an individual a genetic predisposition towards AvPD. Childhood emotional neglect and peer group rejection are both associated with an increased risk for the development of AvPD.
Some researchers believe a combination of high-sensory-processing
sensitivity coupled with adverse childhood experiences may heighten the
risk of an individual developing AvPD.
Subtypes
Millon
Psychologist Theodore Millon notes that because most patients present a mixed picture of symptoms, their personality disorder
tends to be a blend of a major personality disorder type with one or
more secondary personality disorder types. He identified four adult
subtypes of avoidant personality disorder.
| Subtype and description | Personality traits |
|---|---|
| Phobic avoidant (including dependent features) | General apprehensiveness displaced with avoidable tangible precipitant; qualms and disquietude symbolized by repugnant and specific dreadful object or circumstances. |
| Conflicted avoidant (including negativistic features) | Internal discord and dissension; fears dependence; unsettled; unreconciled within self; hesitating, confused, tormented, paroxysmic, embittered; unresolvable angst. |
| Hypersensitive avoidant (including paranoid features) | Intensely wary and suspicious; alternately panicky, terrified, edgy, and timorous, then thin-skinned, high-strung, petulant, and prickly. |
| Self-deserting avoidant (including depressive features) | Blocks or fragments self awareness; discards painful images and memories; casts away untenable thoughts and impulses; ultimately jettisons self (suicidal). |
Others
In 1993, Lynn E. Alden and Martha J. Capreol proposed two other subtypes of avoidant personality disorder:
| Subtype | Features |
|---|---|
| Cold-avoidant | Characterised by an inability to experience and express positive emotion towards others. |
| Exploitable-avoidant | Characterised by an inability to express anger towards others or to resist coercion from others. May be at risk for abuse by others. |
Diagnosis
WHO
The World Health Organization's ICD-10 lists avoidant personality disorder as anxious (avoidant) personality disorder (F60.6).
It is characterized by at least four of the following:
- persistent and pervasive feelings of tension and apprehension;
- belief that one is socially inept, personally unappealing, or inferior to others;
- excessive preoccupation with being criticized or rejected in social situations;
- unwillingness to become involved with people unless certain of being liked;
- restrictions in lifestyle because of need to have physical security;
- avoidance of social or occupational activities that involve significant interpersonal contact because of fear of criticism, disapproval, or rejection.
- Associated features may include hypersensitivity to rejection and criticism.
It is a requirement of ICD-10 that all personality disorder diagnoses also satisfy a set of general personality disorder criteria.
APA
The Diagnostic and Statistical Manual of Mental Disorders (DSM) of the APA
also has an Avoidant Personality Disorder diagnosis (301.82). It refers
to a widespread pattern of inhibition around people, feeling inadequate
and being very sensitive to negative evaluation. Symptoms begin by
early adulthood and occur in a range of situations. Four of seven
specific symptoms should be present, which are the following:
- Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection
- Is unwilling to get involved with people unless certain of being liked
- Shows restraint within intimate relationships because of the fear of being shamed or ridiculed
- Is preoccupied with being criticized or rejected in social situations
- Is inhibited in new interpersonal situations because of feelings of inadequacy
- Views self as socially inept, personally unappealing, or inferior to others
- Is unusually reluctant to take personal risk or to engage in any new activities because they may prove embarrassing
Differential diagnosis
In contrast to social anxiety disorder, a diagnosis of avoidant personality disorder (AvPD) also requires that the general criteria for a personality disorder are met.
According to the DSM-5 avoidant personality disorder must be differentiated from similar personality disorders such as dependent, paranoid, schizoid, and schizotypal.
But these can also occur together; this is particularly likely for
AvPD and dependent personality disorder. Thus, if criteria for more than
one personality disorder are met, all can be diagnosed.
There is also an overlap between avoidant and schizoid personality traits and AvPD may have a relationship to the schizophrenia spectrum.
Treatment
Treatment of avoidant personality disorder can employ various techniques, such as social skills training, psychotherapy, cognitive therapy, and exposure treatment to gradually increase social contacts, group therapy for practicing social skills, and sometimes drug therapy.
A key issue in treatment is gaining and keeping the patient's
trust, since people with avoidant personality disorder will often start
to avoid treatment sessions if they distrust the therapist or fear
rejection. The primary purpose of both individual therapy and social
skills group training is for individuals with avoidant personality
disorder to begin challenging their exaggerated negative beliefs about
themselves.
Significant improvement in the symptoms of personality disorders is possible, with the help of treatment and individual effort.
Prognosis
Being
a personality disorder, which are usually chronic and long-lasting
mental conditions, avoidant personality disorder is not expected to
improve with time without treatment. It is a poorly studied personality
disorder and in light of prevalence rates, societal costs, and the
current state of research, AvPD qualifies as a neglected disorder.
Controversy
There is controversy as to whether avoidant personality disorder (AvPD) is distinct from generalized social anxiety disorder.
Both have similar diagnostic criteria and may share a similar
causation, subjective experience, course, treatment and identical
underlying personality features, such as shyness.
It is contended by some that they are merely different
conceptualisations of the same disorder, where avoidant personality
disorder may represent the more severe form.
In particular, those with AvPD experience not only more severe social
phobia symptoms, but are also more depressed and more functionally
impaired than patients with generalized social phobia alone. But they show no differences in social skills or performance on an impromptu speech. Another difference is that social phobia is the fear of social circumstances whereas AvPD is better described as an aversion to intimacy in relationships.
Epidemiology
Data from the 2001–02 National Epidemiologic Survey on Alcohol and Related Conditions indicates a prevalence rate of 2.36% in the American general population. It appears to occur with equal frequency in males and females. In one study, it was seen in 14.7% of psychiatric outpatients.
History
The
avoidant personality has been described in several sources as far back
as the early 1900s, although it was not so named for some time. Swiss psychiatrist Eugen Bleuler described patients who exhibited signs of avoidant personality disorder in his 1911 work Dementia Praecox: Or the Group of Schizophrenias. Avoidant and schizoid patterns were frequently confused or referred to synonymously until Kretschmer (1921), in providing the first relatively complete description, developed a distinction.
