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Saturday, December 29, 2018

Social exclusion

From Wikipedia, the free encyclopedia
Social exclusion, or social marginalisation, is the social disadvantage and relegation to the fringe of society. It is a term used widely in Europe and was first used in France. It is used across disciplines including education, sociology, psychology, politics and economics.

Social exclusion is the process in which individuals or people are systematically blocked from (or denied full access to) various rights, opportunities and resources that are normally available to members of a different group, and which are fundamental to social integration and observance of human rights within that particular group (e.g., housing, employment, healthcare, civic engagement, democratic participation, and due process).

Alienation or disenfranchisement resulting from social exclusion can be connected to a person's social class, race, skin color, religious affiliation, ethnic origin, educational status, childhood relationships, living standards, or appearance. Such exclusionary forms of discrimination may also apply to people with a disability, minorities, LGBTQ+ people, drug users, institutional care leavers, the elderly and the young. Anyone who appears to deviate in any way from perceived norms of a population may thereby become subject to coarse or subtle forms of social exclusion.

The outcome of social exclusion is that affected individuals or communities are prevented from participating fully in the economic, social, and political life of the society in which they live. This may result to a resistance in form of demonstrations, protests, or lobbying from the excluded people.

Overview

Most of the characteristics listed in this article are present together in studies of social exclusion, due to exclusion's multidimensionality. 

Another way of articulating the definition of social exclusion is as follows:
Social exclusion is a multidimensional process of progressive social rupture, detaching groups and individuals from social relations and institutions and preventing them from full participation in the normal, normatively prescribed activities of the society in which they live.
In an alternative conceptualization, social exclusion theoretically emerges at the individual or group level on four correlated dimensions: insufficient access to social rights, material deprivation, limited social participation and a lack of normative integration. It is then regarded as the combined result of personal risk factors (age, gender, race); macro-societal changes (demographic, economic and labor market developments, technological innovation, the evolution of social norms); government legislation and social policy; and the actual behavior of businesses, administrative organizations and fellow citizens.

Individual exclusion

The marginal man...is one whom fate has condemned to live in two societies and in two, not merely different but antagonistic cultures....his mind is the crucible in which two different and refractory cultures may be said to melt and, either wholly or in part, fuse.
Social exclusion at the individual level results in an individual's exclusion from meaningful participation in society. An example is the exclusion of single mothers from the welfare system prior to welfare reforms of the 1900s. The modern welfare system is based on the concept of entitlement to the basic means of being a productive member of society both as an organic function of society and as compensation for the socially useful labor provided. A single mother's contribution to society is not based on formal employment, but on the notion that provision of welfare for children is a necessary social expense. In some career contexts, caring work is devalued and motherhood is seen as a barrier to employment. Single mothers were previously marginalized in spite of their significant role in the socializing of children due to views that an individual can only contribute meaningfully to society through "gainful" employment as well as a cultural bias against unwed mothers. When the father's sole task was seen as the breadwinner, his marginalization was primarily a function of class condition. Solo fatherhood brings additional trials due to society being less accepting of males 'getting away with' not working and the general invisibility/lack of acknowledgement of single fathers in society. Acknowledgement of the needs participatory fathers may have can be found by examining the changes from the original clinical report on the father’s role published by the American Academy of Pediatrics in May 2004. Eight week paternity leave is a good example of one social change. Child health care providers have an opportunity to have a greater influence on the child and family structure by supporting fathers and enhancing a father's involvement.

More broadly, many women face social exclusion. Moosa-Mitha discusses the Western feminist movement as a direct reaction to the marginalization of white women in society. Women were excluded from the labor force and their work in the home was not valued. Feminists argued that men and women should equally participate in the labor force, in the public and private sector, and in the home. They also focused on labor laws to increase access to employment as well as to recognize child-rearing as a valuable form of labor. In some places today, women are still marginalized from executive positions and continue to earn less than men in upper management positions.

Another example of individual marginalization is the exclusion of individuals with disabilities from the labor force. Grandz discusses an employer's viewpoint about hiring individuals living with disabilities as jeopardizing productivity, increasing the rate of absenteeism, and creating more accidents in the workplace. Cantor also discusses employer concern about the excessively high cost of accommodating people with disabilities. The marginalization of individuals with disabilities is prevalent today, despite the legislation intended to prevent it in most western countries, and the academic achievements, skills and training of many disabled people.

There are also exclusions of lesbian-gay-bisexual-transgender (LGBT) and other intersexual people because of their sexual orientations and gender identities. The Yogyakarta Principles require that the states and communities abolish any stereotypes about LGBT people as well as stereotyped gender roles.
Isolation is common to almost every vocational, religious or cultural group of a large city. Each develops its own sentiments, attitudes, codes, even its own words, which are at best only partially intelligible to others.

Community exclusion

Many communities experience social exclusion, such as racial (e.g., black) (e.g., Untouchables or Low Castes or Dalits in Indian Caste System ) and economic (e.g., Romani) communities. 

One example is the Aboriginal community in Australia. Marginalization of Aboriginal communities is a product of colonization. As a result of colonialism, Aboriginal communities lost their land, were forced into destitute areas, lost their sources of livelihood, and were excluded from the labor market. Additionally, Aboriginal communities lost their culture and values through forced assimilation and lost their rights in society. Today various Aboriginal communities continue to be marginalized from society due to the development of practices, policies and programs that "met the needs of white people and not the needs of the marginalized groups themselves". Yee also connects marginalization to minority communities, when describing the concept of whiteness as maintaining and enforcing dominant norms and discourse. Poor people living in run-down council estates and areas with high crime can be locked into social deprivation.

Other contributors

Social exclusion has many contributors. Major contributors include race, income, employment status, social class, geographic location, personal habits and appearance, education, religion and political affiliation.

Global and structural

Globalization (global-capitalism), immigration, social welfare and policy are broader social structures that have the potential to contribute negatively to one's access to resources and services, resulting in the social exclusion of individuals and groups. Similarly, increasing use of information technology and company outsourcing have contributed to job insecurity and a widening gap between the rich and the poor. Alphonse, George & Moffat (2007) discuss how globalization sets forth a decrease in the role of the state with an increase in support from various "corporate sectors resulting in gross inequalities, injustices and marginalization of various vulnerable groups" (p. 1). Companies are outsourcing, jobs are lost, the cost of living continues to rise, and land is being expropriated by large companies. Material goods are made in large abundances and sold at cheaper costs, while in India for example, the poverty line is lowered in order to mask the number of individuals who are actually living in poverty as a result of globalization. Globalization and structural forces aggravate poverty and continue to push individuals to the margins of society, while governments and large corporations do not address the issues (George, P, SK8101, lecture, October 9, 2007).

Certain language and the meaning attached to language can cause universalizing discourses that are influenced by the Western world, which is what Sewpaul (2006) describes as the "potential to dilute or even annihilate local cultures and traditions and to deny context specific realities" (p. 421). What Sewpaul (2006) is implying is that the effect of dominant global discourses can cause individual and cultural displacement, as well as an experience of "de-localization", as individual notions of security and safety are jeopardized (p. 422). Insecurity and fear of an unknown future and instability can result in displacement, exclusion, and forced assimilation into the dominant group. For many, it further pushes them to the margins of society or enlists new members to the outskirts because of global-capitalism and dominant discourses (Sewpaul, 2006).

With the prevailing notion of globalization, we now see the rise of immigration as the world gets smaller and smaller with millions of individuals relocating each year. This is not without hardship and struggle of what a newcomer thought was going to be a new life with new opportunities. Ferguson, Lavalette, & Whitmore (2005) discuss how immigration has had a strong link to access of welfare support programs. Newcomers are constantly bombarded with the inability to access a country's resources because they are seen as "undeserving foreigners" (p. 132). With this comes a denial of access to public housing, health care benefits, employment support services, and social security benefits (Ferguson et al., 2005). Newcomers are seen as undeserving, or that they must prove their entitlement in order to gain access to basic support necessities. It is clear that individuals are exploited and marginalized within the country they have emigrated (Ferguson et al., 2005).

Welfare states and social policies can also exclude individuals from basic necessities and support programs. Welfare payments were proposed to assist individuals in accessing a small amount of material wealth (Young, 2000). Young (2000) further discusses how "the provision of the welfare itself produces new injustice by depriving those dependent on it of rights and freedoms that others have…marginalization is unjust because it blocks the opportunity to exercise capacities in socially defined and recognized way" (p. 41). There is the notion that by providing a minimal amount of welfare support, an individual will be free from marginalization. In fact, welfare support programs further lead to injustices by restricting certain behaviour, as well the individual is mandated to other agencies. The individual is forced into a new system of rules while facing social stigma and stereotypes from the dominant group in society, further marginalizing and excluding individuals (Young, 2000). Thus, social policy and welfare provisions reflect the dominant notions in society by constructing and reinforcing categories of people and their needs. It ignores the unique-subjective human essence, further continuing the cycle of dominance (Wilson & Beresford, 2000).

Unemployment

Whilst recognizing the multi-dimensionality of exclusion, policy work undertaken at European Union level focuses on unemployment as a key cause of, or at least correlating with, social exclusion. This is because in modern societies, paid work is not only the principal source of income with which to buy services, but is also the fount of individuals' identity and feeling of self-worth. Most people's social networks and sense of embeddedness in society also revolve around their work. Many of the indicators of extreme social exclusion, such as poverty and homelessness, depend on monetary income which is normally derived from work. Social exclusion can be a possible result of long-term unemployment, especially in countries with weak welfare safety nets. Much policy to reduce exclusion thus focuses on the labour market:
  • On the one hand, to make individuals at risk of exclusion more attractive to employers, i.e. more "employable".
  • On the other hand, to encourage (and/or oblige) employers to be more inclusive in their employment policies.
The EU's EQUAL Community Initiative investigated ways to increase the inclusiveness of the labour market. Work on social exclusion more broadly is carried out through the Open Method of Coordination (OMC) among the Member State governments.

Religion

Some religious traditions recommend excommunication of individuals said to deviate from a religious teaching, and in some instances shunning by family members. Some religious organisations permit the censure of critics. 

Across societies, individuals and communities can be socially excluded on the basis of their religious beliefs. Social hostility against religious minorities and communal violence occur in areas where governments do not have policies restricting the religious practise of minorities. A study by the Pew Research Center on international religious freedom found that 61% of countries have social hostilities that tend to target religious minorities. The five highest social hostility scores were for Pakistan, India, Sri Lanka, Iraq, and Bangladesh. In 2015, Pew published that social hostilities declined in 2013, but Harassment of Jews increased.

Social inclusion

Social inclusion, the converse of social exclusion, is affirmative action to change the circumstances and habits that lead to (or have led to) social exclusion. The World Bank defines social inclusion as the process of improving the ability, opportunity, and dignity of people, disadvantaged on the basis of their identity, to take part in society. The World Bank's 2019 World Development Report on The Changing Nature of Work suggests that enhanced social protection and better investments in human capital improve equality of opportunity and social inclusion.

Social Inclusion ministers have been appointed, and special units established, in a number of jurisdictions around the world. The first Minister for Social Inclusion was Premier of South Australia Mike Rann, who took the portfolio in 2004. Based on the UK's Social Exclusion Unit, established by Prime Minister Tony Blair in 1997, Rann established the Social Inclusion Initiative in 2002. It was headed by Monsignor David Cappo and was serviced by a unit within the department of Premier and Cabinet. Cappo sat on the Executive Committee of the South Australian Cabinet and was later appointed Social Inclusion Commissioner with wide powers to address social disadvantage. Cappo was allowed to roam across agencies given that most social disadvantage has multiple causes necessitating a "joined up" rather than a single agency response. The Initiative drove a big investment by the South Australian Government in strategies to combat homelessness, including establishing Common Ground, building high quality inner city apartments for "rough sleeping" homeless people, the Street to Home initiative and the ICAN flexible learning program designed to improve school retention rates. It also included major funding to revamp mental health services following Cappo's "Stepping Up" report, which focused on the need for community and intermediate levels of care and an overhaul of disability services. In 2007 Australian Prime Minister Kevin Rudd appointed Julia Gillard as the nation's first Social Inclusion Minister.

In Japan, the concept and term "social inclusion" went through a number of changes over time and eventually became incorporated in community-based activities under the monikers hōsetsu (包摂) and hōkatsu (包括), such as in the "Community General Support Centres" (chiiki hōkatsu shien sentā 地域包括支援センター) and "Community-based Integrated Care System" (chiiki hōkatsu kea shisutemu 地域包括ケアシステム).

Consequences

Health

In gay men, results of psycho-emotional damage from marginalization from a heteronormative society, suicide, and drug addiction.

Scientists have been studying the impact of racism on health. Amani Nuru-Jeter, a social epidemiologist at the University of California, Berkeley and other doctors have been hypothesizing that exposure to chronic stress may be one way racism contributes to health disparities between racial groups. Arline Geronimus, a research professor at the University of Michigan Institute for Social Research and a professor at the School of Public Health, and her colleagues found that psychosocial associated with living in extreme poverty can cause early onset of age-related diseases. The 2015 study titled, "Race-Ethnicity, Poverty, Urban Stressors, and Telomere Length in a Detroit Community-based Sample" was conducted in order to determine the impact of living conditions on health and was performed by a multi-university team of social scientists, cellular biologists and community partners, including the Healthy Environments Partnership (HEP) to measured the telomere length of poor and moderate-income people of White, African-American and Mexican race.

In 2006, there was research focused on possible connections between exclusion and brain function. Studies published by both the University of Georgia and San Diego State University found that exclusion can lead to diminished brain functioning and poor decision making. Such studies corroborate with earlier beliefs of sociologists. The effect of social exclusion have been hypothesized in various past research studies to correlate with such things as substance abuse and addiction, and crime.

Economics

The problem of social exclusion is usually tied to that of equal opportunity, as some people are more subject to such exclusion than others. Marginalisation of certain groups is a problem in many economically more developed countries, including the United Kingdom and the United States, where the majority of the population enjoys considerable economic and social opportunities.

In philosophy

The marginal, the processes of marginalisation, etc. bring specific interest in postmodern and postcolonial philosophy and social studies. Postmodernism question the "center" about its authenticity and postmodern sociology and cultural studies research marginal cultures, behaviors, societies, the situation of the marginalized individual, etc.

Implications for social work practice

Upon defining and describing marginalization as well as the various levels in which it exists, one must now explore its implications for social work practice. Mullaly (2007) describes how "the personal is political" and the need for recognizing that social problems are indeed connected with larger structures in society, causing various forms of oppression amongst individuals resulting in marginalization. It is also important for the social worker to recognize the intersecting nature of oppression. A non-judgmental and unbiased attitude is necessary on the part of the social worker. The worker must begin to understand oppression and marginalization as a systemic problem, not the fault of the individual.

Working under an anti-oppression perspective would then allow the social worker to understand the lived, subjective experiences of the individual, as well as their cultural, historical and social background. The worker should recognize the individual as political in the process of becoming a valuable member of society and the structural factors that contribute to oppression and marginalization (Mullaly, 2007). Social workers must take a firm stance on naming and labeling global forces that impact individuals and communities who are then left with no support, leading to marginalization or further marginalization from the society they once knew (George, P, SK8101, lecture, October 9, 2007).

The social worker should be constantly reflexive, work to raise the consciousness, empower, and understand the lived subjective realities of individuals living in a fast-paced world, where fear and insecurity constantly subjugate the individual from the collective whole, perpetuating the dominant forces, while silencing the oppressed.

Some individuals and groups who are not professional social workers build relationships with marginalized persons by providing relational care and support, for example, through homeless ministry. These relationships validate the individuals who are marginalized and provide them a meaningful contact with the mainstream.

Juridical concept

There are countries, Italy for example, that have a legal concept of social exclusion. In Italy, "esclusione sociale" is defined as poverty combined with social alienation, by the statute n. 328 (11-8-2000), that instituted a state investigation commission named "Commissione di indagine sull'Esclusione Sociale" (CIES) to make an annual report to the government on legally expected issues of social exclusion.

The Vienna Declaration and Programme of Action, a document on international human rights instruments affirms that "extreme poverty and social exclusion constitute a violation of human dignity and that urgent steps are necessary to achieve better knowledge of extreme poverty and its causes, including those related to the program of development, in order to promote the human rights of the poorest, and to put an end to extreme poverty and social exclusion and promote the enjoyment of the fruits of social progress. It is essential for States to foster participation by the poorest people in the decision making process by the community in which they live, the promotion of human rights and efforts to combat extreme poverty."

Quotations

Social exclusion is about the inability of our society to keep all groups and individuals within reach of what we expect as a society...[or] to realise their full potential.

Whatever the content and criteria of social membership, socially excluded groups and individuals lack capacity or access to social opportunity.

To be "excluded from society" can take various relative senses, but social exclusion is usually defined as more than a simple economic phenomenon: it also has consequences on the social, symbolic field. 
Women of Pakistani, Bangladeshi and Caribbean descent [in Britain] are doing well in schools but are still being penalised in the workplace...80-89% of 16-year-olds from those ethnic groups wanted to work full-time...but they were up to four times more likely to be jobless.

Philosopher Axel Honneth thus speaks of a "struggle for recognition", which he attempts to theorize through Hegel's philosophy. In this sense, to be socially excluded is to be deprived from social recognition and social value. In the sphere of politics, social recognition is obtained by full citizenship; in the economic sphere (in capitalism) it means being paid enough to be able to participate fully in the life of the community.

This concept can be gleaned from considering examples of the "social integration crisis: poverty, professional exclusion or marginalization, social and civic disenfranchisement, absence or weakening of support networks, frequent inter-cultural conflicts", These relate not only to gender, race and disability, but also to crime:
Social exclusion is a major cause of crime and re-offending. Removing the right to vote increases social exclusion by signalling to serving prisoners that, at least for the duration of their sentence, they are dead to society. The additional punishment of disenfranchisement is not a deterrent. There is no evidence to suggest that criminals are deterred from offending behaviour by the threat of losing the right to vote.....(and) the notion of civic death for sentenced prisoners isolates still further those who are already on the margins of society and encourages them to be seen as alien to the communities to which they will return on release.

Avoidant personality disorder

From Wikipedia, the free encyclopedia

Avoidant personality disorder
SynonymsAnxious personality disorder
SpecialtyPsychiatry

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:
  1. persistent and pervasive feelings of tension and apprehension;
  2. belief that one is socially inept, personally unappealing, or inferior to others;
  3. excessive preoccupation with being criticized or rejected in social situations;
  4. unwillingness to become involved with people unless certain of being liked;
  5. restrictions in lifestyle because of need to have physical security;
  6. 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:
  1. Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection
  2. Is unwilling to get involved with people unless certain of being liked
  3. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed
  4. Is preoccupied with being criticized or rejected in social situations
  5. Is inhibited in new interpersonal situations because of feelings of inadequacy
  6. Views self as socially inept, personally unappealing, or inferior to others
  7. 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.

Loneliness

From Wikipedia, the free encyclopedia

 
Loneliness is a complex and usually unpleasant emotional response to isolation. Loneliness typically includes anxious feelings about a lack of connection or communication with other beings, both in the present and extending into the future. As such, loneliness can be felt even when surrounded by other people. The causes of loneliness are varied and include social, mental, emotional, and physical factors. 

Research has shown that loneliness is prevalent throughout society, including people in marriages, relationships, families, veterans, and those with successful careers. It has been a long explored theme in the literature of human beings since classical antiquity. Loneliness has also been described as social pain—a psychological mechanism meant to motivate an individual to seek social connections. Loneliness is often defined in terms of one's connectedness to others, or more specifically as "the unpleasant experience that occurs when a person's network of social relations is deficient in some important way".

Common causes

People can experience loneliness for many reasons, and many life events may cause it, such as a lack of friendship relations during childhood and adolescence, or the physical absence of meaningful people around a person. At the same time, loneliness may be a symptom of another social or psychological problem, such as chronic depression

Many people experience loneliness for the first time when they are left alone as infants. It is also a very common, though normally temporary, consequence of a breakup, divorce, or loss of any important long-term relationship. In these cases, it may stem both from the loss of a specific person and from the withdrawal from social circles caused by the event or the associated sadness.

The loss of a significant person in one's life will typically initiate a grief response; in this situation, one might feel lonely, even while in the company of others. Loneliness may also occur after the birth of a child (often expressed in postpartum depression), after marriage, or following any other socially disruptive event, such as moving from one's home town into an unfamiliar community, leading to homesickness. Loneliness can occur within unstable marriages or other close relationships of a similar nature, in which feelings present may include anger or resentment, or in which the feeling of love cannot be given or received. Loneliness may represent a dysfunction of communication, and can also result from places with low population densities in which there are comparatively few people to interact with. Loneliness can also be seen as a social phenomenon, capable of spreading like a disease. When one person in a group begins to feel lonely, this feeling can spread to others, increasing everybody's risk for feelings of loneliness. People can feel lonely even when they are surrounded by other people.

A twin study found evidence that genetics account for approximately half of the measurable differences in loneliness among adults, which was similar to the heritability estimates found previously in children. These genes operate in a similar manner in males and females. The study found no common environmental contributions to adult loneliness.

Typology

Feeling lonely vs. being socially isolated

There is a clear distinction between feeling lonely and being socially isolated (for example, a loner). In particular, one way of thinking about loneliness is as a discrepancy between one's necessary and achieved levels of social interaction, while solitude is simply the lack of contact with people. Loneliness is therefore a subjective experience; if a person thinks they are lonely, then they are lonely. People can be lonely while in solitude, or in the middle of a crowd. What makes a person lonely is the fact that they need more social interaction or a certain type of social interaction that is not currently available. A person can be in the middle of a party and feel lonely due to not talking to enough people. Conversely, one can be alone and not feel lonely; even though there is no one around that person is not lonely because there is no desire for social interaction. There have also been suggestions that each person has their own optimal level of social interaction. If a person gets too little or too much social interaction, this could lead to feelings of loneliness or over-stimulation.

Solitude can have positive effects on individuals. One study found that, although time spent alone tended to depress a person's mood and increase feelings of loneliness, it also helped to improve their cognitive state, such as improving concentration. Furthermore, once the alone time was over, people's moods tended to increase significantly. Solitude is also associated with other positive growth experiences, religious experiences, and identity building such as solitary quests used in rites of passages for adolescents.

Loneliness can also play an important role in the creative process. In some people, temporary or prolonged loneliness can lead to notable artistic and creative expression, for example, as was the case with poets Emily Dickinson and Isabella di Morra, and numerous musicians. This is not to imply that loneliness itself ensures this creativity, rather, it may have an influence on the subject matter of the artist and more likely be present in individuals engaged in creative activities.

Transient vs. chronic loneliness

The other important typology of loneliness focuses on the time perspective. In this respect, loneliness can be viewed as either transient or chronic. It has also been referred to as state and trait loneliness. 

Transient (state) loneliness is temporary in nature, caused by something in the environment, and is easily relieved. Chronic (trait) loneliness is more permanent, caused by the person, and is not easily relieved. For example, when a person is sick and cannot socialize with friends would be a case of transient loneliness. Once the person got better it would be easy for them to alleviate their loneliness. A person who feels lonely regardless of if they are at a family gathering, with friends, or alone is experiencing chronic loneliness. It does not matter what goes on in the surrounding environment, the experience of loneliness is always there.

Loneliness as a human condition

The existentialist school of thought views loneliness as the essence of being human. Each human being comes into the world alone, travels through life as a separate person, and ultimately dies alone. Coping with this, accepting it, and learning how to direct our own lives with some degree of grace and satisfaction is the human condition.

Some philosophers, such as Sartre, believe in an epistemic loneliness in which loneliness is a fundamental part of the human condition because of the paradox between people's consciousness desiring meaning in life and the isolation and nothingness of the universe. Conversely, other existentialist thinkers argue that human beings might be said to actively engage each other and the universe as they communicate and create, and loneliness is merely the feeling of being cut off from this process.

Frequency

There are several estimates and indicators of loneliness. It has been estimated that approximately 60 million people in the United States, or 20% of the total population, feel lonely. Another study found that 12% of Americans have no one with whom to spend free time or to discuss important matters. Other research suggests that this rate has been increasing over time. The General Social Survey found that between 1985 and 2004, the number of people the average American discusses important matters with decreased from three to two. Additionally, the number of Americans with no one to discuss important matters with tripled (though this particular study may be flawed). In the UK research by Age UK shows half a million people more than 60 years old spend each day alone without social interaction and almost half a million more see and speak to no one for 5 or 6 days a week. On the other hand, the Community Life Survey, 2016 to 2017, by the UK's Office for National Statistics, found that young adults in England aged 16 to 24 reported feeling lonely more often than those in older age groups.

Loneliness appears to have intensified in every society in the world as modernization occurs. A certain amount of this loneliness appears to be related to greater migration, smaller household sizes, a larger degree of media consumption (all of which have positive sides as well in the form of more opportunities, more choice in family size, and better access to information), all of which relates to social capital

Within developed nations, loneliness has shown the largest increases among two groups: seniors and people living in low-density suburbs. Seniors living in suburban areas are particularly vulnerable, for as they lose the ability to drive, they often become "stranded" and find it difficult to maintain interpersonal relationships.

Loneliness is prevalent in vulnerable groups in society. In New Zealand the fourteen surveyed groups with the highest prevalence of loneliness most/all of the time in descending order are: disabled, recent migrants, low income households, unemployed, single parents, rural (rest of South Island), seniors aged 75+, not in the labour force, youth aged 15-24, no qualifications, not housing owner-occupier, not in a family nucleus, Māori, and low personal income.

Americans seem to report more loneliness than any other country, though this finding may simply be an effect of greater research volume. A 2006 study in the American Sociological Review found that Americans on average had only two close friends in which to confide, which was down from an average of three in 1985. The percentage of people who noted having no such confidant rose from 10% to almost 25%, and an additional 19% said they had only a single confidant, often their spouse, thus raising the risk of serious loneliness if the relationship ended. The modern office environment has been demonstrated to give rise to loneliness. This can be especially prevalent in individuals prone to social isolation who can interpret the business focus of co-workers for a deliberate ignoring of needs.

Whether a correlation exists between Internet usage and loneliness is a subject of controversy, with some findings showing that Internet users are lonelier and others showing that lonely people who use the Internet to keep in touch with loved ones (especially seniors) report less loneliness, but that those trying to make friends online became lonelier. On the other hand, studies in 2002 and 2010 found that "Internet use was found to decrease loneliness and depression significantly, while perceived social support and self-esteem increased significantly" and that the Internet "has an enabling and empowering role in people's lives, by increasing their sense of freedom and control, which has a positive impact on well-being or happiness." The one apparently unequivocal finding of correlation is that long driving commutes correlate with dramatically higher reported feelings of loneliness (as well as other negative health impacts).

Effects

Mental health

Loneliness by Hans Thoma (National Museum in Warsaw)
 
Loneliness has been linked with depression, and is thus a risk factor for suicide. Émile Durkheim has described loneliness, specifically the inability or unwillingness to live for others, i.e. for friendships or altruistic ideas, as the main reason for what he called egoistic suicide. In adults, loneliness is a major precipitant of depression and alcoholism. People who are socially isolated may report poor sleep quality, and thus have diminished restorative processes. Loneliness has also been linked with a schizoid character type in which one may see the world differently and experience social alienation, described as the self in exile.

In children, a lack of social connections is directly linked to several forms of antisocial and self-destructive behavior, most notably hostile and delinquent behavior. In both children and adults, loneliness often has a negative impact on learning and memory. Its disruption of sleep patterns can have a significant impact on the ability to function in everyday life.

Research from a large-scale study published in the journal Psychological Medicine, showed that "lonely millennials are more likely to have mental health problems, be out of work and feel pessimistic about their ability to succeed in life than their peers who feel connected to others, regardless of gender or wealth".

Pain, depression, and fatigue function as a symptom cluster and thus may share common risk factors. Two longitudinal studies with different populations demonstrated that loneliness was a risk factor for the development of the pain, depression, and fatigue symptom cluster over time. These data also highlight the health risks of loneliness; pain, depression, and fatigue often accompany serious illness and place people at risk for poor health and mortality.

Physical health

Chronic loneliness can be a serious, life-threatening health condition. It has been found to be associated with an increased risk of stroke and cardiovascular disease. Loneliness shows an increased incidence of high blood pressure, high cholesterol, and obesity.

Loneliness is shown to increase the concentration of cortisol levels in the body. Prolonged, high cortisol levels can cause anxiety, depression, digestive problems, heart disease, sleep problems, and weight gain.

″Loneliness has been associated with impaired cellular immunity as reflected in lower natural killer (NK) cell activity and higher antibody titers to the Epstein Barr Virus and human herpes viruses". Because of impaired cellular immunity, loneliness among young adults shows vaccines, like the flu vaccine, to be less effective. Data from studies on loneliness and HIV positive men suggests loneliness increases disease progression.

Physiological mechanisms link to poor health

There are a number of potential physiological mechanisms linking loneliness to poor health outcomes. In 2005, results from the American Framingham Heart Study demonstrated that lonely men had raised levels of Interleukin 6 (IL-6), a blood chemical linked to heart disease. A 2006 study conducted by the Center for Cognitive and Social Neuroscience at the University of Chicago found loneliness can add thirty points to a blood pressure reading for adults over the age of fifty. Another finding, from a survey conducted by John Cacioppo from the University of Chicago, is that doctors report providing better medical care to patients who have a strong network of family and friends than they do to patients who are alone. Cacioppo states that loneliness impairs cognition and willpower, alters DNA transcription in immune cells, and leads over time to high blood pressure. Lonelier people are more likely to show evidence of viral reactivation than less lonely people. Lonelier people also have stronger inflammatory responses to acute stress compared with less lonely people; inflammation is a well known risk factor for age-related diseases.

When someone feels left out of a situation, they feel excluded and one possible side effect is for their body temperature to decrease. When people feel excluded blood vessels at the periphery of the body may narrow, preserving core body heat. This class protective mechanism is known as vasoconstriction.

Treatments and prevention

There are many different ways used to treat loneliness, social isolation, and clinical depression. The first step that most doctors recommend to patients is therapy. Therapy is a common and effective way of treating loneliness and is often successful. Short-term therapy, the most common form for lonely or depressed patients, typically occurs over a period of ten to twenty weeks. During therapy, emphasis is put on understanding the cause of the problem, reversing the negative thoughts, feelings, and attitudes resulting from the problem, and exploring ways to help the patient feel connected. Some doctors also recommend group therapy as a means to connect with other sufferers and establish a support system. Doctors also frequently prescribe anti-depressants to patients as a stand-alone treatment, or in conjunction with therapy. It may take several attempts before a suitable anti-depressant medication is found.

Alternative approaches to treating depression are suggested by many doctors. These treatments include exercise, dieting, hypnosis, electro-shock therapy, acupuncture, and herbs, amongst others. Many patients find that participating in these activities fully or partially alleviates symptoms related to depression.

Paro, a robot pet seal classified as a medical device by U.S. regulators
 
Another treatment for both loneliness and depression is pet therapy, or animal-assisted therapy, as it is more formally known. Studies and surveys, as well as anecdotal evidence provided by volunteer and community organizations, indicate that the presence of animal companions such as dogs, cats, rabbits, and guinea pigs can ease feelings of depression and loneliness among some sufferers. Beyond the companionship the animal itself provides there may also be increased opportunities for socializing with other pet owners. According to the Centers for Disease Control and Prevention there are a number of other health benefits associated with pet ownership, including lowered blood pressure and decreased levels of cholesterol and triglycerides.

Nostalgia has also been found to have a restorative effect, counteracting loneliness by increasing perceived social support.

A 1989 study found that the social aspect of religion had a significant negative association with loneliness among elderly people. The effect was more consistent than the effect of social relationships with family and friends, and the subjective concept of religiosity had no significant effect on loneliness.

One study compared the effectiveness of four interventions: improving social skills, enhancing social support, increasing opportunities for social interaction, addressing abnormal social cognition (faulty thoughts and patterns of thoughts). The results of the study indicated that all interventions were effective in reducing loneliness, possibly with the exception of social skill training. Results of the meta-analysis suggest that correcting maladaptive social cognition offers the best chance of reducing loneliness.

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