Avoidant personality disorder

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Not to be confused with Antisocial personality disorder.
Anxious [avoidant] personality disorder
Classification and external resources
ICD-10 F60.6
ICD-9 301.82
MedlinePlus 000940
eMedicine ped/189
MeSH D010554

Avoidant personality disorder (AvPD), also known as anxious personality disorder,[1] 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.[2] Individuals afflicted with the disorder tend to describe themselves as ill at ease, anxious, lonely, and generally feel unwanted and isolated from others.[3]

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.[4]

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.[5][6] 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.[7][8][9]

Signs and symptoms[edit]

Avoidant personality disorder is more commonly found to be diagnosed in females than in males. 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.[10] 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,[3] while showing an increased inability to identify traits within themselves which are generally considered as positive within their societies.[11] 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.[4]

Causes[edit]

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.[15][16] 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.[17] These inherited characteristics may give an individual a genetic predisposition towards AvPD.[18] Childhood emotional neglect[19][20][21][22] and peer group rejection[13] are both associated with an increased risk for the development of AvPD.[15]

Millon's subtypes[edit]

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.[23] He identified four adult subtypes of avoidant personality disorder.[24]

Subtype Features
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).[23]

Diagnosis[edit]

World Health Organization[edit]

The World Health Organization's ICD-10 lists avoidant personality disorder as (F60.6) anxious (avoidant) personality disorder.[1] It is characterized by at least four of the following:[25]

  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 a diagnosis of any specific personality disorder also satisfy a set of general personality disorder criteria.

American Psychiatric Association[edit]

The DSM-IV-TR also has an Avoidant Personality Disorder diagnosis. It refers in general to a widespread pattern of inhibition around people, feeling inadequate and being very sensitive to being evaluated negatively since early adulthood and occurring in a range of situations. In addition, four of seven specific criteria should be met, which are:

  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

Other[edit]

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).[26]

Differential diagnosis[edit]

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.[citation needed] 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.[27]

Comorbidity[edit]

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).

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.[28]

Treatment[edit]

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.[29] 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.[30]

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.[31]

Epidemiology[edit]

According to the DSM-IV-TR, avoidant personality disorder occurs in approximately 0.1% to 0.5% of the general population.[32] However, data from the 2001-02 National Epidemiologic Survery on Alcohol and Related Conditions indicates a prevalence rate of the disorder of 0.36% in the American general population.[33] It is seen in about 10% of psychiatric outpatients.[34]

History[edit]

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.[35] Avoidant and schizoid patterns were frequently confused or referred to synonymously until Kretschmer (1921),[36] in providing the first relatively complete description, developed a distinction.

See also[edit]

Social:

References[edit]

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  2. ^ "Avoidant personality disorder"Diagnostic and Statistical Manual of Mental Disorders Fourth edition Text Revision (DSM-IV-TR), American Psychiatric Association (2000)
  3. ^ a b Millon, Theodore; Davis, Roger D. (1996). Disorders of Personality: DSM-IV and Beyond, 2nd Edition. p. 263. 
  4. ^ a b "Avoidant Personality Disorder - Environmental Factors". 
  5. ^ 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. 
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