Avoidant personality disorder

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Avoidant personality disorder
Other namesAnxious personality disorder
Loneliness in a Crowd.jpg
Specialty Psychiatry, clinical psychology
Symptoms Social anxiety, social inhibition, feelings of inadequacy and inferiority, withdrawal
Complications Substance use disorders, self-harm
DurationChronic
Risk factors Childhood emotional neglect, Genetic predisposition
Differential diagnosis Social anxiety disorder, Schizoid personality disorder, Asperger syndrome, Schizotypal personality disorder
Treatment Psychotherapy

Avoidant personality disorder (AvPD) or Anxious personality disorder is a Cluster C personality disorder characterized by excessive social anxiety and inhibition, fear of intimacy (despite an intense desire for it), severe feelings of inadequacy and inferiority, and an overreliance on avoidance of feared stimuli (e.g. self-imposed social isolation) as a maladaptive coping method. [1] Those affected typically display a pattern of extreme sensitivity to negative evaluation and rejection, a belief that one is socially inept or personally unappealing to others, and avoidance of social interaction despite a strong desire for it. [2] It appears to affect an approximately equal number of men and women. [3]

Contents

People with AvPD often avoid social interaction for fear of being ridiculed, humiliated, rejected, or disliked. They typically avoid becoming involved with others unless they are certain they will not be rejected, and may also pre-emptively abandon relationships due to a real or imagined fear that they are at risk of being rejected by the other party. [4]

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. [5]

Signs and symptoms

Avoidant individuals are preoccupied with their own shortcomings and form relationships with others only if they believe they will not be rejected. They often view themselves with contempt, while showing a decreased ability to identify traits within themselves that are generally considered as positive within their societies. [6] Loss and social rejection are so painful that these individuals will choose to be alone rather than risk trying to connect with others.

Some with this disorder fantasize about idealized, accepting, and affectionate relationships because of their desire to belong. They often feel themselves unworthy of the relationships they desire, and shame themselves from ever attempting to begin them. If they do manage to form relationships, it is also common for them to pre-emptively abandon them out of fear of the relationship failing. [4]

Individuals with the disorder tend to describe themselves as uneasy, anxious, lonely, unwanted and isolated from others. [7] They often choose jobs of isolation in which they do not have to interact with others regularly. Avoidant individuals also avoid performing activities in public spaces for fear of embarrassing themselves in front of others.

Symptoms include:

Comorbidity

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 avoidant personality disorder, as well as about 20–40% of people who have social anxiety disorder. In addition to this, AvPD is more prevalent in people who have comorbid social anxiety disorder and generalised anxiety disorder than in those who have only one of the aforementioned conditions. [12]

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. [13] Post-traumatic stress disorder is also commonly comorbid with avoidant personality disorder. [14]

Avoidants are prone to self-loathing and, in certain cases, self-harm. Substance use disorders are also common in individuals with AvPD—particularly in regard to alcohol, benzodiazepines, and opioids [9] —and may significantly affect a patient's prognosis. [10] [11]

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). [15]

Causes

Causes of AvPD are not clearly defined, [16] 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. [17] [18]

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. [19] These inherited characteristics may give an individual a genetic predisposition towards AvPD. [20]

Childhood emotional neglect [21] [22] [23] [24] and peer group rejection [25] are both associated with an increased risk for the development of AvPD. [17] Some researchers believe a combination of high-sensory-processing sensitivity coupled with adverse childhood experiences may heighten the risk of an individual developing AvPD. [26]

Subtypes

Millon

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 descriptionPersonality traits
Phobic avoidant (including dependent features)General apprehensiveness displaced with avoidable tangible precipitant; qualms and disquietude symbolized by a 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; possibly suicidal. [28]

Others

In 1993, Lynn E. Alden and Martha J. Capreol proposed two other subtypes of avoidant personality disorder: [29]

SubtypeFeatures
Cold-avoidantCharacterised by an inability to experience and express positive emotion towards others.
Exploitable-avoidantCharacterised by an inability to express anger towards others or to resist coercion from others. May be at risk for abuse by others.

Diagnosis

ICD

The World Health Organization's ICD-10 lists avoidant personality disorder as anxious (avoidant) personality disorder (F60.6).

It is characterized by the presence of at least four of the following: [1]

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.

DSM

The Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association 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 the following seven specific symptoms should be present: [2]

Differential diagnosis

In contrast to social anxiety disorder, a diagnosis of avoidant personality disorder (AvPD) also requires that the general criteria for a personality disorder be 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]

Avoidant personality disorder must also be differentiated from the autism spectrum, specifically Asperger syndrome. [31]

Treatment

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. [32]

A key issue in treatment is gaining and keeping the patient's trust since people with an 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 an avoidant personality disorder to begin challenging their exaggerated negative beliefs about themselves. [33]

Significant improvement in the symptoms of personality disorders is possible, with the help of treatment and individual effort. [34]

Prognosis

Being a personality disorder, which is usually chronic and has long-lasting mental conditions, an avoidant personality disorder may not improve with time without treatment. Given that 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. [35]

Controversy

There is debate as to whether avoidant personality disorder (AvPD) is distinct from 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. [36] [37] [38]

It is contended by some that they are merely different conceptualizations of the same disorder, where avoidant personality disorder may represent the more severe form. [39] [40] 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. [40] But they show no differences in social skills or performance on an impromptu speech. [41] Another difference is that social phobia is the fear of social circumstances whereas AvPD is better described as an aversion to intimacy in relationships. [32]

Epidemiology

Data from the 2001–02 National Epidemiologic Survey on Alcohol and Related Conditions indicates a prevalence of 2.36% in the American general population. [42] It appears to occur with equal frequency in males and females. [3] In one study, it was seen in 14.7% of psychiatric outpatients. [43]

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. [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

Social:

Related Research Articles

<span class="mw-page-title-main">Phobia</span> Anxiety disorder classified by a persistent and excessive fear of an object or situation

A phobia is an anxiety disorder, defined by an irrational, unrealistic, persistent and excessive fear of an object or situation. Phobias typically result in a rapid onset of fear and are usually present for more than six months. Those affected go to great lengths to avoid the situation or object, to a degree greater than the actual danger posed. If the object or situation cannot be avoided, they experience significant distress. Other symptoms can include fainting, which may occur in blood or injury phobia, and panic attacks, often found in agoraphobia and emetophobia. Around 75% of those with phobias have multiple phobias.

<span class="mw-page-title-main">Anxiety disorder</span> Cognitive disorder with an excessive, irrational dread of everyday situations

Anxiety disorders are a cluster of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social, occupational, and personal functions are significantly impaired. Anxiety may cause physical and cognitive symptoms, such as restlessness, irritability, easy fatigue, difficulty concentrating, increased heart rate, chest pain, abdominal pain, and a variety of other symptoms that may vary based on the individual.

<span class="mw-page-title-main">Agoraphobia</span> Anxiety disorder

Agoraphobia is a mental and behavioral disorder, specifically an anxiety disorder characterized by symptoms of anxiety in situations where the person perceives their environment to be unsafe with no easy way to escape. These situations can include public transit, shopping centers, crowds and queues, or simply being outside their home on their own. Being in these situations may result in a panic attack. Those affected will go to great lengths to avoid these situations. In severe cases, people may become completely unable to leave their homes.

Specific phobia is an anxiety disorder, characterized by an extreme, unreasonable, and irrational fear associated with a specific object, situation, or concept which poses little or no actual danger. Specific phobia can lead to avoidance of the object or situation, persistence of the fear, and significant distress or problems functioning associated with the fear. A phobia can be the fear of anything.

<span class="mw-page-title-main">Borderline personality disorder</span> Personality disorder of emotional instability

Borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD), is a personality disorder characterized by a pervasive, long-term pattern of significant interpersonal relationship instability, a distorted sense of self, and intense emotional responses. Individuals diagnosed with BPD frequently exhibit self-harming behaviours and engage in risky activities, primarily due to challenges in regulating emotional states to a healthy, stable baseline. Symptoms such as dissociation—a feeling of detachment from reality, a pervasive sense of emptiness, and an acute fear of abandonment are prevalent among those affected.

<span class="mw-page-title-main">Narcissistic personality disorder</span> Personality disorder

Narcissistic personality disorder (NPD) is a personality disorder characterized by a life-long pattern of exaggerated feelings of self-importance, an excessive need for admiration, and a diminished ability to empathize with other people's feelings. Narcissistic personality disorder is one of the sub-types of the broader category known as personality disorders. It is often comorbid with other mental disorders and associated with significant functional impairment and psychosocial disability.

<span class="mw-page-title-main">Schizoid personality disorder</span> Medical condition

Schizoid personality disorder is a personality disorder characterized by a lack of interest in social relationships, a tendency toward a solitary or sheltered lifestyle, secretiveness, emotional coldness, detachment, and apathy. Affected individuals may be unable to form intimate attachments to others and simultaneously possess a rich and elaborate but exclusively internal fantasy world. Other associated features include stilted speech, a lack of deriving enjoyment from most activities, feeling as though one is an "observer" rather than a participant in life, an inability to tolerate emotional expectations of others, apparent indifference when praised or criticized, a degree of asexuality, and idiosyncratic moral or political beliefs.

<span class="mw-page-title-main">Dependent personality disorder</span> Personality disorder

Dependent personality disorder (DPD) is a personality disorder characterized by a pervasive psychological dependence on other people. This personality disorder is a long-term condition in which people depend on others to meet their emotional and physical needs. Dependent personality disorder is a cluster C personality disorder, which is characterized by excessive fear and anxiety. It begins prior to early adulthood, and it is present in a variety of contexts and is associated with inadequate functioning. Symptoms can include anything from extreme passivity, devastation or helplessness when relationships end, avoidance of responsibilities, and severe submission.

Schizotypal personality disorder, also known as schizotypal disorder, is a cluster A personality disorder. The Diagnostic and Statistical Manual of Mental Disorders (DSM) classification describes the disorder specifically as a personality disorder characterized by thought disorder, paranoia, a characteristic form of social anxiety, derealization, transient psychosis, and unconventional beliefs. People with this disorder feel pronounced discomfort in forming and maintaining social connections with other people, primarily due to the belief that other people harbor negative thoughts and views about them. Peculiar speech mannerisms and socially unexpected modes of dress are also characteristic. Schizotypal people may react oddly in conversations, not respond, or talk to themselves. They frequently interpret situations as being strange or having unusual meanings for them; paranormal and superstitious beliefs are common. Schizotypal people usually disagree with the suggestion that their thoughts and behaviors are a 'disorder' and seek medical attention for depression or anxiety instead. Schizotypal personality disorder occurs in approximately 3% of the general population and is more commonly diagnosed in males.

Paranoid personality disorder (PPD) is a mental disorder characterized by paranoia, and a pervasive, long-standing suspiciousness and generalized mistrust of others. People with this personality disorder may be hypersensitive, easily insulted, and habitually relate to the world by vigilant scanning of the environment for clues or suggestions that may validate their fears or biases. They are eager observers and they often think they are in danger and look for signs and threats of that danger, potentially not appreciating other interpretations or evidence.

Taijin kyofusho is a Japanese culture-specific syndrome. The term taijin kyofusho translates into the disorder (sho) of fear (kyofu) of interpersonal relations (taijin). Those who have taijin kyofusho are likely to be extremely embarrassed about themselves or fearful of displeasing others when it comes to the functions of their bodies or their appearances. These bodily functions and appearances include their faces, odor, actions, or even looks. They do not want to embarrass other people with their presence. This culture-bound syndrome is a social phobia based on fear and anxiety.

Atypical depression is defined in the DSM-IV as depression that shares many of the typical symptoms of major depressive disorder or dysthymia but is characterized by improved mood in response to positive events. In contrast to those with atypical depression, people with melancholic depression generally do not experience an improved mood in response to normally pleasurable events. Atypical depression also often features significant weight gain or an increased appetite, hypersomnia, a heavy sensation in the limbs, and interpersonal rejection sensitivity that results in significant social or occupational impairment.

A spectrum disorder is a disorder that includes a range of linked conditions, sometimes also extending to include singular symptoms and traits. The different elements of a spectrum either have a similar appearance or are thought to be caused by the same underlying mechanism. In either case, a spectrum approach is taken because there appears to be "not a unitary disorder but rather a syndrome composed of subgroups". The spectrum may represent a range of severity, comprising relatively "severe" mental disorders through to relatively "mild and nonclinical deficits".

Avoidant/restrictive food intake disorder (ARFID) is a feeding or eating disorder in which people avoid eating certain foods, or restrict their diets to the point it ultimately results in nutritional deficiencies. This can be due to the sensory characteristics of food, such as its appearance, smell, texture, or taste; due to fear of negative consequences such as choking or vomiting; having little interest in eating or food, or a combination of these factors. People with ARFID may also be afraid of trying new foods, a fear known as food neophobia.

Social anxiety is the anxiety and fear specifically linked to being in social settings. Some categories of disorders associated with social anxiety include anxiety disorders, mood disorders, autism spectrum disorders, eating disorders, and substance use disorders. Individuals with higher levels of social anxiety often avert their gazes, show fewer facial expressions, and show difficulty with initiating and maintaining a conversation. Social anxiety commonly manifests itself in the teenage years and can be persistent throughout life; however, people who experience problems in their daily functioning for an extended period of time can develop social anxiety disorder. Trait social anxiety, the stable tendency to experience this anxiety, can be distinguished from state anxiety, the momentary response to a particular social stimulus. Half of the individuals with any social fears meet the criteria for social anxiety disorder. Age, culture, and gender impact the severity of this disorder. The function of social anxiety is to increase arousal and attention to social interactions, inhibit unwanted social behavior, and motivate preparation for future social situations.

Personality disorders (PD) are a class of mental disorders characterized by enduring maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by the individual's culture. These patterns develop early, are inflexible, and are associated with significant distress or disability. The definitions vary by source and remain a matter of controversy. Official criteria for diagnosing personality disorders are listed in the sixth chapter of the International Classification of Diseases (ICD) and in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM).

Asociality refers to the lack of motivation to engage in social interaction, or a preference for solitary activities. Asociality may be associated with avolition, but it can, moreover, be a manifestation of limited opportunities for social relationships. Developmental psychologists use the synonyms nonsocial, unsocial, and social uninterest. Asociality is distinct from, but not mutually exclusive to, anti-social behavior. A degree of asociality is routinely observed in introverts, while extreme asociality is observed in people with a variety of clinical conditions.

<span class="mw-page-title-main">Social anxiety disorder</span> Anxiety disorder associated with social situations

Social anxiety disorder (SAD), also known as social phobia, is an anxiety disorder characterized by sentiments of fear and anxiety in social situations, causing considerable distress and impairing ability to function in at least some aspects of daily life. These fears can be triggered by perceived or actual scrutiny from others. Individuals with social anxiety disorder fear negative evaluations from other people.

The relationship between schizoid personality disorder (SzPD) and avoidant personality disorder (AvPD) has been a subject of controversy for decades.

Separation anxiety disorder (SAD) is an anxiety disorder in which an individual experiences excessive anxiety regarding separation from home and/or from people to whom the individual has a strong emotional attachment. Separation anxiety is a natural part of the developmental process. It is most common in infants and little children, typically between the ages of six to seven months to three years, although it may pathologically manifest itself in older children, adolescents and adults. Unlike SAD, normal separation anxiety indicates healthy advancements in a child's cognitive maturation and should not be considered a developing behavioral problem.

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