Avoidant Personality Disorder

Agoraphobia

hikikomori

Avoidant personality disorder (or anxious personality disorder) is a personality disorder recognized in the Diagnostic and Statistical Manual of Mental Disorders handbook in a person characterized by 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 a 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 1911. Avoidant and schizoid patterns were frequently confused or referred to synonymously until Kretschmer, who provided the first relatively complete description in 1921, developed a distinction.

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. Other signs and symptoms include:  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; 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, although others may find the relationship with them meaningful; feeling inferior to others; in some more extreme cases — agoraphobia; and the use of fantasy as a form of escapism and to interrupt painful thoughts.

The 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.

The World Health Organization’s ICD-10 lists avoidant personality disorder as (F60.6) anxious (avoidant) personality disorder. It is characterized by at least four of the following: 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.

Psychologist Theodore Millon identified four subtypes of avoidant personality disorder. Any individual avoidant may exhibit none or one of the following: First, conflicted avoidant – including negativistic features; the conflicted avoidant feels ambivalent towards themselves and others. They can idealize those close to them but under stress they may feel under-appreciated or misunderstood and wish to hurt others in revenge. They may be perceived as petulant or to be sulking. Second, hypersensitive avoidant – including paranoid features; the hypersensitive avoidant experiences paranoia, mistrustfulness and fear, but to a lesser extent than an individual with paranoid personality disorder. They may be perceived as petulant or ‘high-strung.’ Third, phobic avoidant – including dependent features. Fourth, self-deserting avoidant – including depressive features.

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, who are aware of the irrationality of their phobia yet are unable to control it, people with avoidant personality disorder are unaware of or reject the idea that their fears are excessive and believe with full conviction that they are inadequate, unlovable, broken, etc.

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.

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. 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 avoidant personality disorder, called ‘avoidant-borderline mixed personality’ (AvPD/BPD).

There is also significant overlap between avoidant personality disorder and autism spectrum disorders.

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.

However, because of the deep-seated feelings of inferiority and extreme social fear, it is unlikely that those with AvPD will ever overcome the disorder entirely, with the prognosis being even worse for those low-functioning persons as they are likely to drop out of treatment if they become too anxious.

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