Avoidant personality disorder

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Avoidant personality disorder
Synonyms Anxious personality disorder
Specialty Psychiatry

Avoidant personality disorder (AvPD) is a Cluster C personality disorder.[1] 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.[2] The behavior is usually noticed by early adulthood and occurs in most situations.[2]

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 avoidant personality disorder is avoidance of feared stimuli.[1] Both 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.[3]

Some researchers have theorized that 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.[4]

Signs and symptoms[edit]

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.[5] They often feel themselves unworthy of the relationships they desire, so they shame themselves from ever attempting to begin them.[6]

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 social rejection are so painful that these individuals will choose to be alone rather than risk trying to connect with others (see rejection sensitivity). They often view themselves with contempt,[5] while showing an increased inability to identify traits within themselves that are generally considered as positive within their societies.[7]

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 anxiety disorder. In addition to this, avoidant personality disorder is more prevalent in persons who have comorbid social anxiety disorder and generalised anxiety disorder than in those who have only one of the aforementioned conditions.[13]

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.[14] Posttraumatic stress disorder is also commonly comorbid with avoidant personality disorder.[15]

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).[15] Substance use disorders are also common in individuals with AvPD—particularly in regards to alcohol, benzodiazepines and heroin[10]—and may significantly affect a patient's prognosis.[11][12]

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).[16]

Causes[edit]

Causes of avoidant personality disorder are not clearly defined,[17] 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.[18][19] 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.[20] These inherited characteristics may give an individual a genetic predisposition towards avoidant personality disorder.[21] Childhood emotional neglect[22][23][24][25] and peer group rejection[26] are both associated with an increased risk for the development of avoidant personality disorder.[18] Some researchers believe that a combination of high sensory processing sensitivity coupled with adverse childhood experiences may heighten the risk of an individual developing AvPD.[4]

Subtypes[edit]

Millon[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. He identified four adult subtypes of avoidant personality disorder.[27][28]

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).[28]

Others[edit]

In 1993, Alden and Capreol proposed two other subtypes of avoidant personality disorder:[29]

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[edit]

WHO[edit]

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]

  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[edit]

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:[2]

  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[edit]

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.[2]

There is also an overlap between avoidant and schizoid personality traits (see schizoid avoidant behavior) and AvPD may have a relationship to the schizophrenia spectrum.[30]

Treatment[edit]

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.[31]

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.[32]

Significant improvement in the symptoms of personality disorders is possible, with the help of treatment and individual effort.[33]

Prognosis[edit]

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.[34]

Controversy[edit]

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.[35][36][37]

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.[38][39] 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.[39] But they show no differences in social skills or performance on an impromptu speech.[40] Another difference is that social phobia is the fear of social circumstances whereas AvPD is better described as an aversion to intimacy in relationships.[31]

Epidemiology[edit]

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.[41] It appears to occur with equal frequency in males and females.[42] In one study, it was seen in 14.7% of psychiatric outpatients.[43]

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.[44] Avoidant and schizoid patterns were frequently confused or referred to synonymously until Kretschmer (1921),[45] in providing the first relatively complete description, developed a distinction.

See also[edit]

Social:

References[edit]

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  2. ^ a b c d American Psychiatric Association (2013). "Avoidant Personality Disorder (pp. 672–675)". Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). doi:10.1176/appi.books.9780890425596.156852. ISBN 978-0-89042-555-8. 
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