Avoidant personality disorder

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Not to be confused with Antisocial personality disorder.
Anxious [avoidant] personality disorder
SpecialtyPsychiatry, psychology Edit this on Wikidata
Personality disorders
Cluster A (odd)
Cluster B (dramatic)
Cluster C (anxious)
Not otherwise specified
Depressive
Others

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 a person when they display a pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation, and avoidance of social interaction.[2]

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.[3][4] 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.[5][6][7]

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.[8] Avoidant and schizoid patterns were frequently confused or referred to synonymously until Kretschmer (1921),[9] 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.

Causes

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.[13][14] 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.[15] These inherited characteristics may give an individual a genetic predisposition towards AvPD.[16] Childhood emotional neglect[17][18][19][20] and peer group rejection[11] are both associated with an increased risk for the development of AvPD.[13]

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.[21] He identified four adult subtypes of avoidant personality disorder.[22]

Subtype Features
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).[23]

Diagnosis

World Health Organization

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:[24]

  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

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

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).[25]

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.[26]

Comorbidity

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.[27]

Treatment

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.[28] 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.[29]

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.[30]

Epidemiology

According to the DSM-IV-TR, avoidant personality disorder occurs in approximately 0.5% to 1% of the general population.[31] 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.[32] It is seen in about 10% of psychiatric outpatients.[33]

See also

Social:

References

  1. ^ a b Avoidant personality disorder - International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10)
  2. ^ Avoidant personality disorder - Diagnostic and Statistical Manual of Mental Disorders Fourth edition Text Revision (DSM-IV-TR) American Psychiatric Association (2000)
  3. ^ 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.
  4. ^ 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.
  5. ^ Ralevski, E.; Sanislow, C. A.; Grilo, C. M.; Skodol, A. E.; Gunderson, J. G.; Tracie Shea, M.; Yen, S.; Bender, D. S.; Zanarini, M. C. (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.
  6. ^ 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.
  7. ^ 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.
  8. ^ Millon, Theodore; Martinez, Alexandra (1995). "Avoidant Personality Disorder". In Livesley, W. John (ed.). The DSM-IV Personality Disorders. Guilford Press. p. 218. ISBN 0-89862-257-3.
  9. ^ Kretschmer, Ernst (1921). Körperbau und Charakter. J. Springer. {{cite book}}: Cite has empty unknown parameter: |coauthors= (help)
  10. ^ Gary Gilles M.A., Paula Ford-Martin M.A. (2003). "Avoidant personality disorder". Avoidant personality disorder. Healthline Networks. Retrieved 2006-02-26.
  11. ^ a b 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. {{cite book}}: External link in |chapterurl= (help); Unknown parameter |chapterurl= ignored (|chapter-url= suggested) (help)
  12. ^ Avoidant Personality Disorder, Real Mental Health, Inc.
  13. ^ a b 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.
  14. ^ Rettew, David C. (March 4, 2008). "Avoidant Personality Disorder". eMedicine. Archived from the original on 12 February 2010. Retrieved January 26, 2010. {{cite web}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); Unknown parameter |deadurl= ignored (|url-status= suggested) (help)
  15. ^ 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.
  16. ^ Lenzenweger, Mark F.; Clarkin, John F. (2005). Major Theories of Personality Disorder. Guilford Press. p. 69. ISBN 1-59385-108-1.
  17. ^ 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.
  18. ^ 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.
  19. ^ 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.
  20. ^ Battle, Cynthia L.; Shea, M. Tracie; Johnson, Dawn M.; Yen, Shirley; Zlotnick, Caron; Zanarini, Mary C.; Sanislow, Charles A.; Skodol, Andrew E.; Gunderson, John G. (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.18.2.193.32777. PMID 15176757.
  21. ^ Millon, Theadore. "Personality Subtypes Summary". http://www.millon.net. Institute for Advanced Studies in Personology and Psychopathology. Retrieved 8 January 2013. {{cite web}}: External link in |work= (help)
  22. ^ Millon, Theodore (2004). Personality Disorders in Modern Life. John Wiley & Sons, Inc., Hoboken, New Jersey. ISBN 0-471-23734-5.
  23. ^ Millon, Theadore. "Personality Subtypes Summary". http://www.millon.net. Institute for Advanced Studies in Personology and Psychopathology. Retrieved 8 January 2013. {{cite web}}: External link in |work= (help)
  24. ^ WHO.int
  25. ^ Kantor, M. (1993, revised 2003). Distancing: A guide to avoidance and avoidant personality disorder. Westport, Conn: Praeger Publishers.
  26. ^ 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.
  27. ^ Van Velzen, C. J. M. (2002). Social phobia and personality disorders: Comorbidity and treatment issues. Groningen: University Library Groningen. (online version)
  28. ^ Comer, R. J. (1996). Fundamentals of abnormal psychology. Avoidant personality disorder, pp.428-430. Third edition. New York: Worth.
  29. ^ 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.
  30. ^ "Avoidant personality disorder". Healthline Networks. 2003. Retrieved 25 October 2011.
  31. ^ Webb, James T.; Amend, Edward R.; Webb, Nadia (2005). "Ideational and Anxiety Disorders". Misdiagnosis and dual diagnoses of gifted children and adults: Attention Deficit Hyperactivity Disorder, bipolar, Obsessive Compulsive Disorder, Asperger's, depression, and other disorders. Great Potential Press, Inc. p. 112. ISBN 0-910707-67-7.
  32. ^ 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.
  33. ^ Internet Mental Health - avoidant personality disorder
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