Avoidant personality disorder

Avoidant personality disorder
Other names: Anxious personality disorder
Video explanation of cluster C personality disorders
SpecialtyPsychiatry
SymptomsExcessive fear of social rejection, feelings of inadequacy[1][2]
ComplicationsSuicide[3]
Usual onsetBy early adulthood[1]
DurationLong term[3]
Risk factorsFamily history, childhood emotional neglect[3]
Differential diagnosisAnxiety (including social phobia), schizoid personality disorder, dependent personality disorder[3][1]
TreatmentCognitive behavioral therapy, interpersonal therapy[3]
Frequency2%[3]
Personality disorders
Cluster A (odd)
Cluster B (dramatic)
Cluster C (anxious)
Not specified

Avoidant personality disorder (AvPD) is a personality disorder characterized by a long term pattern of an excessive fear of social rejection and feelings of inadequacy.[1][2] This results in the active avoidance of interpersonal contact both in work and social situations.[1] Symptoms are present by at least early adulthood.[1] Associated disorder may include depression, substance use, and eating disorders.[3]

Risk factors include family history and childhood emotional neglect.[3] Diagnosis requires symptoms to be of a degree that affects functioning and the taking into account of cultural and ethnic norms.[3][1] It is a cluster C personality disorder.[3] Some view it as a severe form of social anxiety disorder.[3]

Treatment may involve cognitive behavioral therapy or interpersonal therapy.[3] About half of people improve within 10 years.[3] About 2% of people are affected.[3] Women and men appear to be affected equally frequently.[3] It was introduce in 1980 in the DSM III.[3]

Signs and symptoms

Word cloud for AvPD

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 an increased inability to identify traits within themselves that are generally considered as positive within their societies.[4] 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 due to 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 preemptively abandon them due to fear of the relationship failing.[5]

Individuals with the disorder tend to describe themselves as uneasy, anxious, lonely, unwanted and isolated from others.[6] 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 due to their fear of embarrassing themselves in front of others.

Symptoms include:

  • Extreme shyness or anxiety in social situations, though the person feels a strong desire for close relationships[7]
  • Heightened attachment-related anxiety, which may include a fear of abandonment[8]
  • Substance abuse and/or dependence[9][10][11]

Associated conditions

AvPD is especially common in people with anxiety disorders, although estimates of comorbidity vary 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] Posttraumatic stress disorder is also commonly comorbid with avoidant personality disorder.[14]

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).[14] Substance use disorders are also common in individuals with AvPD—particularly in regard to alcohol, benzodiazepines and heroin[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]

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:[2]

  • 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.

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 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 the following seven specific symptoms should be present:[1]

  • Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection
  • is unwilling to get involved with people unless certain of being liked
  • shows restraint within intimate relationships because of the fear of being shamed or ridiculed
  • is preoccupied with being criticized or rejected in social situations
  • is inhibited in new interpersonal situations because of feelings of inadequacy
  • views self as socially inept, personally unappealing, or inferior to others
  • is unusually reluctant to take personal risk or to engage in any new activities because they may prove embarrassing

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 description Personality 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; ultimately jettisons self (suicidal).[28]

Others

In 1993, Lynn E. Alden and Martha J. 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.

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 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.[1]

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]

There is controversy as to whether 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.[31][32][33]

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.[34][35] 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.[35] But they show no differences in social skills or performance on an impromptu speech.[36] Another difference is that social phobia is the fear of social circumstances whereas AvPD is better described as an aversion to intimacy in relationships.[37]

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.[37]

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.[38]

Significant improvement in the symptoms of personality disorders is possible, with the help of treatment and individual effort.[39]

Prognosis

Being a personality disorder, which is usually chronic and long-lasting mental conditions, an avoidant personality disorder is not expected to 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.[40]

Epidemiology

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

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

  • Attachment theory
  • Avoidance coping
  • Counterphobic attitude
  • Experiential avoidance
  • Inferiority complex
  • Sensory processing sensitivity'
  • Hermit
  • Hikikomori
  • Loner
  • Recluse
  • Solitude
  • Taijin kyofusho

References

  1. 1 2 3 4 5 6 7 8 9 Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). American Psychiatric Association. 2013. pp. 672-675. doi:10.1176/appi.books.9780890425596.156852. ISBN 978-0-89042-555-8. {{cite book}}: Cite has empty unknown parameter: |1= (help)
  2. 1 2 3 The ICD-10 Classification of Mental and Behavioural Disorders (PDF). Geneva: World Health Organization. 1992. Archived (PDF) from the original on 2016-06-18. Retrieved 2020-10-04.
  3. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Fariba, K; Sapra, A (January 2020). "Avoidant Personality Disorder". PMID 32644751. {{cite journal}}: Cite journal requires |journal= (help)
  4. ↑ Will, Retzlaff, ed. (1995). p. 97
  5. ↑ Hoeksema, Nolen (2014). Abnormal Psychology (6th ed.). McGraw Education. p. 275. ISBN 9781308211503.
  6. ↑ Millon, Theodore; Davis, Roger D. (1996). Disorders of Personality: DSM-IV and Beyond, 2nd Edition. p. 263.
  7. ↑ Gary Gilles M.A.; Paula Ford-Martin M.A. (2003). "Avoidant personality disorder". Healthline Networks. Archived from the original on 2007-09-28. Retrieved 2006-02-26.
  8. ↑ Eikenaes, Ingeborg; Pedersen, Geir; Wilberg, Theresa (September 2016). "Attachment styles in patients with avoidant personality disorder compared with social phobia". Psychology and Psychotherapy. 89 (3): 245–260. doi:10.1111/papt.12075. hdl:10852/50233. ISSN 2044-8341. PMID 26332087.
  9. 1 2 Verheul, R (2001-08-01). "Co-morbidity of personality disorders in individuals with substance use disorders". European Psychiatry. 16 (5): 274–282. doi:10.1016/S0924-9338(01)00578-8. PMID 11514129.
  10. 1 2 "Personality disorders and substance use - National Drug Strategy" (PDF). National Drug Strategy. Archived (PDF) from the original on 2018-03-27.
  11. 1 2 "Personality + substance use" (PDF). National Drug and Alcohol Research Centre. Archived (PDF) from the original on 2017-12-04.
  12. ↑ Sanderson, William C.; Wetzler, Scott; Beck, Aaron T.; Betz, Frank (February 1994). "Prevalence of personality disorders among patients with anxiety disorders". Psychiatry Research. 51 (2): 167–174. doi:10.1016/0165-1781(94)90036-1. PMID 8022951. S2CID 13101675.
  13. ↑ Van Velzen, C. J. M. (2002). Social Phobia and Personality Disorders: Comorbidity and Treatment Issues. Groningen: University Library Groningen. (online version)
  14. 1 2 Gratz, Kim L.; Tull, Matthew T. (2012-08-30). "Exploring the relationship between posttraumatic stress disorder and deliberate self-harm: the moderating roles of borderline and avoidant personality disorders". Psychiatry Research. 199 (1): 19–23. doi:10.1016/j.psychres.2012.03.025. ISSN 0165-1781. PMC 3407331. PMID 22521897.
  15. ↑ Kantor, M. (1993, revised 2003). Distancing: A Guide to Avoidance and Avoidant Personality Disorder. Westport, Conn: Praeger Publishers.
  16. ↑ Sederer, Lloyd I. (2009). Blueprints psychiatry (5th ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins. p. 29. ISBN 978-0-7817-8253-1. Archived from the original on 2017-01-11. Retrieved 2016-09-23.
  17. 1 2 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.
  18. ↑ Rettew, David C.; Michael S Jellinek; Alicia C Doyle (March 4, 2008). "Avoidant Personality Disorder". eMedicine. Archived from the original on 12 February 2010. Retrieved January 26, 2010. {{cite journal}}: Cite journal requires |journal= (help)
  19. ↑ Suzanne M. Sutherland, M.D. (2006). "Avoidant Personality Disorder Causes, Frequency, Siblings and Mortality — Morbidity". Avoidant Personality Disorder. Armenian Medical Network. Archived from the original on 2007-09-30. Retrieved 2007-02-26.
  20. ↑ Lenzenweger, Mark F.; Clarkin, John F. (2005). Major Theories of Personality Disorder. Guilford Press. p. 69. ISBN 978-1-59385-108-8. Archived from the original on 2017-01-11. Retrieved 2016-09-23.
  21. ↑ 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.
  22. ↑ 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.
  23. ↑ 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.
  24. ↑ Battle, Cynthia L.; Shea, M. Tracie; Johnson, Dawn M.; Yen, Shirley; Zlotnick, Caron; Zanarini, Mary C.; Sanislow, Charles A.; Skodol, Andrew E.; et al. (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. Archived from the original on 2019-01-08. Retrieved 2019-07-10.
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  26. ↑ Meyer, Björn; Ajchenbrenner, Muriel; Bowles, David P. (December 2005). "Sensory sensitivity, attachment experiences, and rejection responses among adults with borderline and avoidant features". Journal of Personality Disorders. 19 (6): 641–658. doi:10.1521/pedi.2005.19.6.641. ISSN 0885-579X. PMID 16553560.
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  30. ↑ David L. Fogelson; Keith Nuechterlein (2007). "Avoidant personality disorder is a separable schizophrenia-spectrum personality disorder even when controlling for the presence of paranoid and schizotypal personality disorders". Schizophrenia Research. 91 (1–3): 192–199. CiteSeerX 10.1.1.1019.5817. doi:10.1016/j.schres.2006.12.023. PMC 1904485. PMID 17306508.
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  32. ↑ 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. S2CID 31505197.
  33. ↑ 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. S2CID 23171568.
  34. ↑ 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. S2CID 40728363.
  35. 1 2 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. S2CID 9179813.
  36. ↑ Herbert JD, Hope DA, Bellack AS (1992). "Validity of the distinction between generalized social phobia and avoidant personality disorder". J Abnorm Psychol. 101 (2): 332–9. doi:10.1037/0021-843x.101.2.332. PMID 1583228. Archived from the original on 2020-06-10. Retrieved 2019-12-13.
  37. 1 2 Comer, Ronald (2014). Fundamentals of abnormal psychology (PDF). New York, NY: Worth Publishers. pp. 424–427. ISBN 978-1-4292-9563-5.
  38. ↑ 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.
  39. ↑ "Personality Disorder - Treatment". Mind. Archived from the original on 2016-02-05. Retrieved 5 February 2016.
  40. ↑ Weinbrecht Anna, Schulze Lars, Boettcher Johanna, Renneberg Babette (2016). "Avoidant Personality Disorder: a Current Review". Current Psychiatry Reports. 18 (3): 29. doi:10.1007/s11920-016-0665-6. PMID 26830887. S2CID 34358884.{{cite journal}}: CS1 maint: multiple names: authors list (link).
  41. ↑ 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.
  42. ↑ American Psychiatric Association, ed. (2013). "Avoidant Personality Disorder, 301.82 (F60.6)". Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Publishing. pp. 672–675.
  43. ↑ Zimmerman, M.; Rothschild, L. & Chelminski, I. (2005). "The prevalence of DSM-IV personality disorders in psychiatric outpatients". The American Journal of Psychiatry. 162 (10): 1911–1918. doi:10.1176/appi.ajp.162.10.1911. PMID 16199838.
  44. ↑ Millon, Theodore; Martinez, Alexandra (1995). "Avoidant Personality Disorder". In Livesley, W. John (ed.). The DSM-IV Personality Disorders. Guilford Press. pp. 218. ISBN 978-0-89862-257-7.
  45. ↑ Kretschmer, Ernst (1921). Körperbau und Charakter. J. Springer.
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