Avoidant personality disorder

Not to be confused with antisocial personality disorder. (Clinically, the term "antisocial" denotes a disregard for society's norms and rules, not social inhibition.)

Avoidant personality disorder (AvPD)^[1] (or anxious personality disorder^[2]) is a personality disorder recognized in the DSM-IV TR handbook in a person over the age of eighteen years as characterized by a pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation, and avoidance of social interaction.

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.

AvPD is usually first noticed in early adulthood, and is associated with perceived or actual rejection by parents or peers during childhood. Whether the feeling of rejection is due to the extreme interpersonal monitoring attributed to people with the disorder is still disputed.

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. Avoidant and schizoid patterns were frequently confused or referred to synonymously until Kretschmer (1921),^[3] in providing the first relatively complete description, developed a distinction.

Symptoms

People with AvPD 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 criticism or rejection
• Self-imposed social isolation
• Extreme shyness in social situations, though feels a strong desire for close relationships^[4]
• Avoids physical contact because it has been associated with an unpleasant or painful stimulus
• Avoids interpersonal relationships
• Feelings of inadequacy
• Severe low self-esteem
• Self-loathing
• 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
• Feeling inferior to others
• Utilizes fantasy as a form of escapism and to interrupt painful thoughts^[5]

Diagnostic criteria (DSM-IV-TR = 301.82)

The Diagnostic and Statistical Manual of Mental Disorders fourth edition, DSM IV-TR, a widely used manual for diagnosing mental disorders, defines avoidant personality disorder (in Axis II Cluster C) as:^[1]

A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

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 initiating intimate relationships because of the fear of being ashamed, ridiculed, or rejected due to severe low self-worth
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 risks or to engage in any new activities because they may prove embarrassing

It is a requirement of DSM-IV that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

Diagnostic criteria (ICD-10)

The World Health Organization's ICD-10 lists avoidant personality disorder as (F60.6) Anxious (avoidant) personality disorder.^[2]

It is characterized by at least 3 of the following:

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 satisfies a set of general personality disorder criteria.

Millon's variations

Theodore Millon identified four variations of avoidant ^[6]. Any individual avoidant may exhibit none or one of the following:

• conflicted avoidant - including negativistic (passive-aggressive) features

• hypersensitive avoidant - including paranoid features

• phobic avoidant - including dependent features

• self-deserting avoidant - including depressive features

Differential diagnosis: associated and overlapping conditions

Research suggests that people with AvPD, in common with social phobics, 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 AvPD; they are so preoccupied with monitoring themselves and others that producing fluent speech is difficult.

AvPD 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 AvPD, 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.^[7] Although it is not mentioned in the DSM-IV, earlier theorists have proposed a personality disorder which has a combination of features from borderline personality disorder and AvPD, called "avoidant-borderline mixed personality" (AvPD/BPD).^[8]

Prevalence (epidemiology)

Avoidant personality disorder occurs in about 0.5% to 1% of the general population. It is seen in about 10% of psychiatric outpatients.^[9]

Causes (etiology)

The cause of AvPD is 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.^[10]

Many people diagnosed with AvPD have had painful early experiences of chronic parental and/or societal criticism or rejection. The need to bond with the rejecting parents or peers makes the person with AvPD hungry for relationships, but their longing gradually develops into a defensive shell of self-protection against repeated criticisms.^[4]

Treatment

Treatment of AvPD 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.^[11] A key issue in treatment is gaining and keeping the patient's trust, since people with AvPD 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 AvPD to begin challenging their exaggeratedly negative beliefs about themselves.^[12]

See also

Psychology portal

• Asperger syndrome
• Attachment theory
• DSM-IV codes (personality disorders)
• Hermit
• Highly sensitive person
• Hikikomori
• ICD-10 codes (personality disorders)
• Inferiority complex
• Love-shyness
• Recluse
• Schizoid personality disorder
• Shyness
• Social anxiety
• Social phobia
• Solitude

References

External links

• Terry L. Jones' website about AvPD
• Chat Room for Avoidants
• Internet Support Group for AvPD
• Psychforums section on AvPD*