Avoidant personality disorder

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]

Avoidant personality disorder
Other names	Anxious personality disorder
Specialty	Psychiatry, clinical psychology
Symptoms	Social anxiety, social inhibition, feelings of inadequacy and inferiority, withdrawal
Complications	Substance use disorders, self-harm
Duration	Chronic
Risk factors	Childhood emotional neglect, Genetic predisposition
Differential diagnosis	Social anxiety disorder, Schizoid personality disorder, Asperger syndrome, Schizotypal personality disorder
Treatment	Psychotherapy

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:

• Extreme shyness or anxiety in social situations^[3]
• Heightened attachment-related anxiety, which may include a fear of abandonment^[8]
• Substance use disorders^[9][10][11]

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 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; possibly 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.

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]

• 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 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]

• 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

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

•  Psychology portal

• Attachment theory
• Avoidance coping
• Counterphobic attitude
• Experiential avoidance
• Inferiority complex
• Sensory processing sensitivity

Social:

• Hermit
• Hikikomori
• Loner
• Recluse
• Solitary animal
• Solitude
• Taijin kyofusho

References

1. Anxious [avoidant personality disorder] in ICD-10: Diagnostic Criteria 2016-06-18 at the Wayback Machine and Clinical descriptions and guidelines. 2014-03-23 at the Wayback Machine
2. "Alternative DSM-5 Model for Personality Disorders". Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). American Psychiatric Association. 2013. pp. 234–236. doi:10.1176/appi.books.9780890425596.156852. ISBN 978-0-89042-555-8.
3. 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.
4. Hoeksema N (2014). Abnormal Psychology (6th ed.). McGraw Education. p. 275. ISBN 978-1-308-21150-3.
5. . Archived from the original on 2014-10-28. Retrieved 2013-07-22.
6. Will, Retzlaff, ed. (1995). p. 97
7. Millon T, Davis RD (1996). Disorders of Personality: DSM-IV and Beyond, 2nd Edition. p. 263.
8. Eikenaes I, Pedersen G, Wilberg T (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. 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. S2CID 29066695.
10. "Personality disorders and substance use - National Drug Strategy" (PDF). National Drug Strategy. (PDF) from the original on 2018-03-27.
11. "Personality + substance use" (PDF). National Drug and Alcohol Research Centre. (PDF) from the original on 2017-12-04.
12. Sanderson WC, Wetzler S, Beck AT, Betz F (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 2021-10-30 at the Wayback Machine)
14. Gratz KL, Tull MT (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 (2003) [1993], Distancing: A Guide to Avoidance and Avoidant Personality Disorder (Revised ed.), Westport, Conn: Praeger Publishers
16. Sederer LI (2009). Blueprints psychiatry (5th ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins. p. 29. ISBN 978-0-7817-8253-1.
17. Eggum ND, Eisenberg N, Spinrad TL, Valiente C, Edwards A, Kupfer AS, et al. (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 DC, Michael S Jellinek, Alicia C Doyle (March 4, 2008). "Avoidant Personality Disorder". eMedicine. from the original on 12 February 2010. Retrieved January 26, 2010.
19. Suzanne M. Sutherland, M.D. (2006). "Avoidant Personality Disorder Causes, Frequency, Siblings and Mortality — Morbidity". Avoidant Personality Disorder. Armenian Medical Network. from the original on 2007-09-30. Retrieved 2007-02-26.
20. Lenzenweger MF, Clarkin JF (2005). Major Theories of Personality Disorder. Guilford Press. p. 69. ISBN 978-1-59385-108-8.
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 PR, McKenzie JM, Luty SE, Mulder RT, Carter JD, Sullivan PF, et al. (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:10.1080/j.1440-1614.2003.01263.x. PMID 14636393. S2CID 154962.
23. Johnson JG, 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 CL, Shea MT, Johnson DM, Yen S, Zlotnick C, Zanarini MC, 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.
25. Sperry L (2003). "Avoidant Personality Disorder". Handbook of diagnosis and treatment of DSM-IV-TR personality disorders. Philadelphia: Brunner-Routledge. pp. 59–79. ISBN 978-0-415-93569-2.
26. Meyer B, Ajchenbrenner M, Bowles DP (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.
27. Theodore Millon (2004): Chapter 6 – The Avoidant Personality (p.187). Personality Disorders in Modern Life. 2017-02-07 at the Wayback Machine Wiley, 2nd Edition. ISBN 0-471-23734-5.
28. Millon T (2015). "Personality Subtypes Summary". Institute for Advanced Studies in Personology and Psychopathology (millon.net). from the original on 2017-06-21. Retrieved 2013-01-08.
29. Peter D. McLean, Sheila R. Woody: Anxiety Disorders in Adults: An Evidence-Based Approach to Psychological Treatment. p. 129, ISBN 978-0-19-802759-1.
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.
31. Lehnhardt FG, Gawronski A, Pfeiffer K, Kockler H, Schilbach L, Vogeley K (November 2013). "The Investigation and Differential Diagnosis of Asperger Syndrome in Adults". Deutsches Ärzteblatt International. 110 (45): 755–763. doi:10.3238/arztebl.2013.0755. PMC 3849991. PMID 24290364.
32. Comer R (2014). Fundamentals of abnormal psychology (PDF). New York, NY: Worth Publishers. pp. 424–427. ISBN 978-1-4292-9563-5.
33. Eckleberry, Sharon C. (2000-03-25). . The Dual Diagnosis Pages: From Our Desk. Archived from the original on 2006-12-16. Retrieved 2007-02-06.
34. "Personality Disorder - Treatment". Mind. from the original on 2016-02-05. Retrieved 5 February 2016.
35. 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..
36. Ralevski E, Sanislow CA, Grilo CM, Skodol AE, Gunderson JG, Tracie Shea M, et al. (2005). "Avoidant personality disorder and social phobia: distinct enough to be separate disorders?". Acta Psychiatrica Scandinavica. 112 (3): 208–14. doi:10.1111/j.1600-0447.2005.00580.x. PMID 16095476. S2CID 16517625.
37. Nedic A, Zivanovic O, Lisulov R (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.
38. Reichborn-Kjennerud T, Czajkowski N, Torgersen S, Neale MC, Orstavik RE, Tambs K, et al. (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.
39. Reich J (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.
40. Huppert JD, Strunk DR, Ledley DR, Davidson JR, Foa EB (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.
41. 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.
42. Grant BF, Hasin DS, Stinson FS, Dawson DA, Chou SP, Ruan WJ, et al. (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.
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 T, Martinez A (1995). "Avoidant Personality Disorder". In Livesley WJ (ed.). The DSM-IV Personality Disorders. Guilford Press. pp. 218. ISBN 978-0-89862-257-7.
45. Kretschmer E (1921). Körperbau und Charakter. J. Springer.

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