Avoidant personality disorder
|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 a person when they display a pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation, and avoidance of social interaction.
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 (e.g. bullying) 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 avoidant personality disorder may represent the more severe form. This is argued because 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.
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.
Signs and symptoms 
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 lonely rather than risk trying to connect with others.
- 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 more extreme cases — agoraphobia
- Utilizes fantasy as a form of escapism and 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.
Millon's subtypes 
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 precipant; qualms and disquietude symbolized by repugnant and specific dreadful object or circumstances.|
|Conflicted (including negativistic features)||Internal discord and dissension; fears independence and 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 selfawareness; 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-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:
- 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
Individual researchers and clinicians also do work on personality types related to the official diagnoses. Psychologist Theodore Millon has proposed four subtypes of avoidant personality disorder. These are a 'conflicted avoidant' - including negativistic features, alleged to feel ambivalent towards themselves and others; 'hypersensitive avoidant' - claimed to include paranoid features to a lesser extent than paranoid personality disorder; 'phobic avoidant' - including dependent features; 'self-deserting avoidant' - including depressive features.
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).
Differential diagnosis 
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.
According to the DSM-IV-TR, avoidant personality disorder occurs in approximately 0.5% to 1% of the general population. However, data from the 2001-02 National Epidemiologic Survery on Alcohol and Related Conditions indicates a prevalence rate of the disorder of 2.36% in the American general population. It is seen in about 10% of psychiatric outpatients.
See also 
- Avoidant personality disorder - International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10)
- Avoidant personality disorder - Diagnostic and Statistical Manual of Mental Disorders Fourth edition Text Revision (DSM-IV-TR) American Psychiatric Association (2000)
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