Avoidant personality disorder
|Anxious [avoidant] personality disorder|
|Classification and external resources|
|Cluster A (odd)|
|Cluster B (dramatic)|
|Cluster C (anxious)|
Avoidant personality disorder (AvPD), also known as anxious personality disorder, is a Cluster C personality disorder recognized in the Diagnostic and Statistical Manual of Mental Disorders handbook as afflicting persons when they display a pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation, and avoidance of social interaction. Individuals afflicted with the disorder tend to describe themselves as ill at ease, anxious, lonely, and generally feel unwanted and isolated from others.
People with avoidant personality disorder often consider themselves to be socially inept or personally unappealing and avoid social interaction for fear of being ridiculed, humiliated, rejected, or disliked. Avoidant personality disorder is usually first noticed in early adulthood. Childhood emotional neglect and peer group rejection are both associated with an increased risk for the development of AvPD.
There is controversy as to whether avoidant personality disorder is a distinct disorder from generalized social phobia and it is contended by some that they are merely different conceptualisations of the same disorder, where AvPD may represent the more severe form. Generalized social phobia and avoidant personality disorder have similar diagnostic criteria and may share a similar causation, subjective experience, course, treatment, and identical underlying personality features, such as shyness.
Signs and symptoms
Those with this disorder may 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 afflicted by this disorder may fantasize about idealized, accepting, and affectionate relationships, due to their desire to belong. They often feel themselves unworthy of the relationships they desire so they shame themselves from ever attempting the relationship. People with avoidant personality disorder are preoccupied with their own shortcomings and form relationships with others only if they believe they will not be rejected. Loss and 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 which are generally considered as positive within their societies. Childhood emotional neglect—in particular, the rejection of a child by one or both parents—has been associated with an increased risk for the development of AvPD, as well as rejection by peers.
- Hypersensitivity to rejection/criticism
- Self-imposed social isolation
- Extreme shyness or anxiety in social situations, though the person feels a strong desire for close relationships
- Avoids physical contact because it has been associated with an unpleasant or painful stimulus
- Feelings of inadequacy
- Severe low self-esteem
- Mistrust of others
- Emotional distancing related to intimacy
- Highly self-conscious
- Self-critical about their problems relating to others
- Problems in occupational functioning
- Lonely self-perception, although others may find the relationship with them meaningful
- Feeling inferior to others
- In some extreme cases, agoraphobia
- Uses fantasy as a form of escapism to interrupt painful thoughts
Causes of avoidant personality disorder are not clearly defined and may 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.
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.
|Phobic (including dependent features)||General apprehensiveness displaced with avoidable tangible precipitant; qualms and disquietude symbolized by repugnant and specific dreadful object or circumstances.|
|Conflicted (including negativistic features)||Internal discord and dissension; fears dependence; unsettled; unreconciled within self; hesitating, confused, tormented, paroxysmic, embittered; unresolvable angst.|
|Hypersensitive (including paranoid features)||Intensely wary and suspicious; alternately panicky, terrified, edgy, and timorous, then thin-skinned, high-strung, petulant, and prickly.|
|Self-deserting (including depressive features)||Blocks or fragments self awareness; discards painful images and memories; casts away untenable thoughts and impulses; ultimately jettisons self (suicidal).|
World Health Organization
- 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 a diagnosis of any specific personality disorder also satisfy a set of general personality disorder criteria.
American Psychiatric Association
The DSM-5 also has an Avoidant Personality Disorder diagnosis. 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:
- 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
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).
Research suggests that people with avoidant personality disorder, in common with sufferers of chronic social anxiety disorder (also called social phobia), excessively monitor their own internal reactions when they are involved in social interaction. However, unlike social phobics they also excessively monitor the reactions of the people with whom they are interacting. The extreme tension created by this monitoring may account for the hesitant speech and taciturnity of many people with avoidant personality disorder; they are so preoccupied with monitoring themselves and others that producing fluent speech is difficult.
According to the Diagnostic and Statistical Manual of Mental Disorders, avoidant personality disorder must be differentiated from dependent, paranoid, schizoid and schizotypal personality disorders.
Avoidant personality disorder 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 phobia (social anxiety disorder).
Treatment of avoidant personality disorder can employ various techniques, such as social skills training, cognitive therapy, 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.
People with AvPD can improve social awareness and skills, but with deep-seated feelings of inferiority and significant social fear, these patterns usually do not change dramatically. Antidepressants sometimes are prescribed for AvPD.
Data from the 2001-02 National Epidemiologic Survery 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.
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.
- Attachment theory
- Counterphobic attitude
- Highly sensitive person
- Inferiority complex
- Experiential avoidance
- Avoidance coping
- "Anxious [avoidant] personality disorder". International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10). Retrieved 19 February 2015.
- American Psychiatric Association, ed. (2013). "Avoidant Personality Disorder, 301.82 (F60.6)". Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Publishing. p. 672-675.
- Millon, Theodore; Davis, Roger D. (1996). Disorders of Personality: DSM-IV and Beyond, 2nd Edition. p. 263.
- "Avoidant Personality Disorder - Environmental Factors".
- Reich, James (2009). "Avoidant personality disorder and its relationship to social phobia". Current Psychiatry Reports 11 (1): 89–93. doi:10.1007/s11920-009-0014-0. PMID 19187715.
- Huppert, Jonathan D.; Strunk, Daniel R.; Ledley, Deborah Roth; Davidson, Jonathan R. T.; Foa, Edna B. (2008). "Generalized social anxiety disorder and avoidant personality disorder: structural analysis and treatment outcome". Depression and Anxiety 25 (5): 441–8. doi:10.1002/da.20349. PMID 17618526.
- Ralevski, E.; Sanislow, C. A.; Grilo, C. M.; Skodol, A. E.; Gunderson, J. G.; Tracie Shea, M.; Yen, S.; Bender, D. S. et al. (2005). "Avoidant personality disorder and social phobia: distinct enough to be separate disorders?". Acta Psychiatrica Scandinavica 112 (3): 208–14. doi:10.1111/j.1600-0447.2005.00580.x. PMID 16095476.
- Nedic, Aleksandra; Zivanovic, Olga; Lisulov, Ratomir (2011). "Nosological status of social phobia: contrasting classical and recent literature". Current Opinion in Psychiatry 24 (1): 61–6. doi:10.1097/YCO.0b013e32833fb5a6. PMID 20966756.
- Reichborn-Kjennerud, T.; Czajkowski, N.; Torgersen, S.; Neale, M. C.; Orstavik, R. E.; Tambs, K.; Kendler, K. S. (2007). "The Relationship Between Avoidant Personality Disorder and Social Phobia: A Population-Based Twin Study". American Journal of Psychiatry 164 (11): 1722–8. doi:10.1176/appi.ajp.2007.06101764. PMID 17974938.
- Hoeksema, Nolen (2014). Abnormal Psychology (6th edition ed.). McGraw Education. p. 275. ISBN 9781308211503.
- Will, Retzlaff, ed. (1995). p. 97
- Gary Gilles M.A., Paula Ford-Martin M.A. (2003). "Avoidant personality disorder". Avoidant personality disorder. Healthline Networks. Retrieved 2006-02-26.
- Sperry, Len (2003). "Avoidant Personality Disorder". Handbook of diagnosis and treatment of DSM-IV-TR personality disorders. Philadelphia: Brunner-Routledge. pp. 59–79. ISBN 978-0-415-93569-2.
- Avoidant Personality Disorder, Real Mental Health, Inc.
- Eggum, Natalie D.; Eisenberg, Nancy; Spinrad, Tracy L.; Valiente, Carlos; Edwards, Alison; Kupfer, Anne S.; Reiser, Mark (2009). "Predictors of withdrawal: Possible precursors of avoidant personality disorder". Development and Psychopathology 21 (3): 815–38. doi:10.1017/S0954579409000443. PMC 2774890. PMID 19583885.
- Rettew, David C.; Michael S Jellinek; Alicia C Doyle (March 4, 2008). "Avoidant Personality Disorder". eMedicine. Archived from the original on 12 February 2010. Retrieved January 26, 2010.
- Suzanne M. Sutherland, M.D. (2006). "Avoidant Personality Disorder Causes, Frequency, Siblings and Mortality — Morbidity". Avoidant Personality Disorder. Armenian Medical Network. Retrieved 2007-02-26.
- Lenzenweger, Mark F.; Clarkin, John F. (2005). Major Theories of Personality Disorder. Guilford Press. p. 69. ISBN 1-59385-108-1.
- Johnson, JG; Smailes, EM; Cohen, P; Brown, J; Bernstein, DP (2000). "Associations between four types of childhood neglect and personality disorder symptoms during adolescence and early adulthood: findings of a community-based longitudinal study". Journal of personality disorders 14 (2): 171–87. doi:10.1521/pedi.2000.14.2.171. PMID 10897467.
- Joyce, Peter R.; McKenzie, Janice M.; Luty, Suzanne E.; Mulder, Roger T.; Carter, Janet D.; Sullivan, Patrick F.; Cloninger, C. Robert (2003). "Temperament, childhood environment and psychopathology as risk factors for avoidant and borderline personality disorders". Australian and New Zealand Journal of Psychiatry 37 (6): 756–64. doi:10.1111/j.1440-1614.2003.01263.x. PMID 14636393.
- Johnson, J. G.; Cohen, P; Brown, J; Smailes, EM; Bernstein, DP (1999). "Childhood Maltreatment Increases Risk for Personality Disorders During Early Adulthood". Archives of General Psychiatry 56 (7): 600–6. doi:10.1001/archpsyc.56.7.600. PMID 10401504.
- Battle, Cynthia L.; Shea, M. Tracie; Johnson, Dawn M.; Yen, Shirley; Zlotnick, Caron; Zanarini, Mary C.; Sanislow, Charles A.; Skodol, Andrew E. et al. (2004). "Childhood Maltreatment Associated With Adult Personality Disorders: Findings From the Collaborative Longitudinal Personality Disorders Study". Journal of Personality Disorders 18 (2): 193–211. doi:10.1521/pedi.18.104.22.168777. PMID 15176757.
- Millon, Theadore. "Personality Subtypes Summary". http://www.millon.net. Institute for Advanced Studies in Personology and Psychopathology. Retrieved 8 January 2013.
- Millon, Theodore (2004). Personality Disorders in Modern Life. John Wiley & Sons, Inc., Hoboken, New Jersey. ISBN 0-471-23734-5.
- Kantor, M. (1993, revised 2003). Distancing: A Guide to Avoidance and Avoidant Personality Disorder. Westport, Conn: Praeger Publishers.
- American Psychiatric Association. (2000). "Anxiety disorders." In Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev., pp. 450–456). Washington, D.C.: American Psychiatric Association.
- Van Velzen, C. J. M. (2002). Social Phobia and Personality Disorders: Comorbidity and Treatment Issues. Groningen: University Library Groningen. (online version)
- Comer, R. J. (1996). Fundamentals of Abnormal Psychology. Avoidant personality disorder, pp. 428–430. Third edition. New York: Worth.
- Eckleberry, Sharon C. (2000-03-25). "Dual Diagnosis and the Avoidant Personality Disorder". The Dual Diagnosis Pages: From Our Desk. Archived from the original on 2006-12-16. Retrieved 2007-02-06.
- "Avoidant personality disorder". Healthline Networks. 2003. Retrieved 25 October 2011.
- Grant, Bridget F.; Hasin, Deborah S.; Stinson, Frederick S.; Dawson, Deborah A.; Chou, S. Patricia; Ruan, W. June; Pickering, Roger P. (2004). "Prevalence, Correlates, and Disability of Personality Disorders in the United States". The Journal of Clinical Psychiatry 65 (7): 948–58. doi:10.4088/JCP.v65n0711. PMID 15291684.
- Zimmerman, M., Rothschild, L., & Chelminski, I. (2005). "The prevalence of DSM-IV personality disorders in psychiatric outpatients". The American Journal of Psychiatry 162 (10): 1911-1918.
- Millon, Theodore; Martinez, Alexandra (1995). "Avoidant Personality Disorder". In Livesley, W. John. The DSM-IV Personality Disorders. Guilford Press. p. 218. ISBN 0-89862-257-3.
- Kretschmer, Ernst (1921). Körperbau und Charakter. J. Springer.