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AVOIDANT (ANXIOUS) PERSONALITY DISORDER
 


Prediction: Lasts For Decades

      Occupational-Economic:
  • Avoids work activities that involve significant interpersonal contact because of fear of criticism or rejection
      Wisdom vs Irrationality: N/A
      Courage vs Negative Emotion:
  • Social anxiety (social phobia)
  • Lacks confidence, hypersensitive to rejection
      Helping Others vs Detachment:
  • Social withdrawal, intimacy avoidance, unwilling to get involved with people unless certain of being liked
      Self-Control vs Disinhibition: N/A
      Justice vs Antagonism: N/A
      Medical: N/A


SYNOPSIS

Anxious [Avoidant] Personality Disorder F60.6 - ICD10 Description, World Health Organization

Anxious [avoidant] personality disorder is characterized by feelings of tension and apprehension, insecurity and inferiority. There is a continuous yearning to be liked and accepted, a hypersensitivity to rejection and criticism with restricted personal attachments, and a tendency to avoid certain activities by habitual exaggeration of the potential dangers or risks in everyday situations.
Avoidant Personality Disorder - Diagnostic Criteria, American Psychiatric Association

An individual diagnosed with avoidant personality disorder needs to show at least 4 of the following criteria:

  • Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection.

  • Is unwilling to get involved with people unless they are 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 risks or to engage in any new activities because they may prove embarrassing.
Avoidant personality disorder is a persistent, generalized form of social anxiety disorder (social phobia).
Social Anxiety Disorder (Social Phobia) - Diagnostic Criteria, American Psychiatric Association

An individual diagnosed with social anxiety disorder (social phobia) needs to meet all of the following criteria:

  • Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech). Note: In children, the anxiety must occur in peer settings and not just during interactions with adults.

  • The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others).

  • The social situations almost always provoke fear or anxiety. Note: In children, the fear or anxiety may be experienced by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.

  • The social situations are avoided or endured with intense fear or anxiety.

  • The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.

  • The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

  • The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functiioning.

  • The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

  • The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.

  • If another medical condition (e.g., Parkinson's disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clarly unrelated or is excessive.
Like all personality disorders, avoidant personality disorder is a deeply ingrained and enduring behaviour pattern, manifesting as an inflexible response to a broad range of personal and social situations. This behavior represents an extreme or significant deviation from the way in which the average individual in a given culture relates to others. This behaviour pattern tends to be stable. It causes subjective distress and problems in social performance.

Core Features

Individuals with avoidant personality disorder grow up with excessive social anxiety and withdrawal. They have a longstanding pattern of shyness, feelings of inferiority, and hypersensitivity to rejection/embarrassment. The core features of this disorder are: (1) negative emotion (anxiousness (fear of rejection/embarrassment)), and (2) detachment (withdrawal, intimacy avoidance, and anhedonia [decreased ability to feel pleasure]). This disorder is only diagnosed if: (1) it begins no later than early adulthood, (2) these behaviors occur at home, work, and in the community, and (3) these behaviors lead to clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Lack Of Social Skills And Personality Disorders

There are social skills that are essential for healthy social functioning. Individuals with avoidant personality disorder lack the essential social skills of self-confidence, optimism, and belonging. They lack intimacy and sociabililty (that are also lacking in individuals with schizoid personality disorder).

    Social Skills That Are Lacking In Avoidant Personality Disorder

    SOCIAL SKILL LOW LEVEL HIGH LEVEL
    Self-Confidence Feeling inferior or shy Having a good opinion of one’s self and abilities; socially confident and out-going
    Optimism Pessimism or expecting the worst Having a positive outlook on life; expecting a good outcome; hopeful
    Belonging Fearing rejection by others Feeling liked and accepted by friends, and included in their group; not fearing rejection
    Intimacy Intimacy avoidance Wanting close friendships or intimate romantic relationships
    Sociability Social withdrawal Friendly; interested in social contacts and activities

Avoidant personality disorder and dependent personality disorder are so closely related that they are referred to as the "negative emotion" cluster of personality disorders.

    Social Skills That Are Lacking In The "Negative Emotion" Cluster Of Personality Disorders

    PERSONALITY DISORDER LACKING LACKING LACKING
    Avoidant Personality Self-Confidence (instead has feeling inferior or shy) Optimism (instead has pessimism or expecting the worst) Belonging (instead has fearing rejection by others)
    Dependent Personality Independence (instead has dependence on others) Assertiveness (instead has submissiveness) Peacemaking (instead has inability to handle conflict)

Phobia/Panic/Obession

The social anxiety and withdrawal (shyness) of individuals with this disorder often starts in infancy or childhood. Most children grow out of their shyness. However, for some individuals during adolescence, this shyness develops into an intense fear of rejection/embarrassment which would be diagnosed as social anxiety disorder (social phobia). By early adulthood, if this social phobia increases still further; the individual would be diagnosed as having avoidant personality disorder. Social anxiety disorder (social phobia) and avoidant personality disorder have similar symptoms, genetics, and treatment response. Thus avoidant personality disorder is merely a more persistent and generalized form of social anxiety disorder (social phobia).

Avoidant-Dependent Traits

Individuals with avoidant personality disorder have an active desire for friendships, but it is constrained by a fear of rejection. Thus they form relationships with others only if they believe they will not be rejected. Loss and rejection are so painful that these individuals would rather be lonely than risk rejection. They usually have feelings of inadequacy, hypersensitivity to criticism, and an excessive need for reassurance.

    Avoidant Personality Traits
    • Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection.
    • Is unwilling to get involved with people unless they are 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 risks or to engage in any new activities because they may prove embarrassing.

Effective Therapies

Avoidant personality disorder is a very common disorder; yet there is surprisingly little research on the effectiveness of its treatment. Thus far, in randomized controlled clinical trials, only cognitive behavioral therapy (graduated exposure) and group therapy have been shown to be partially effective.

Ineffective Therapies

In one randomized controlled clinical trial, brief dynamic therapy was found to be ineffective in the treatment of this disorder.

Which Behavioral Dimensions Are Involved?

The ancient Greek civilization lasted for 1,300 years (8th century BC to 6th century AD). The ancient Greek philosophers taught that the 5 pillars of their civilization were: wisdom, courage, helping others, self-control, and justice. Psychiatry named the opposite of each of these 5 ancient themes as being a major dimension of psychopathology (i.e., irrationality, negative emotion, detachment, disinhibition, and antagonism). (Psychology named these same factors the "Big 5 dimensions of personality": "intellect", "neuroticism", "extraversion", "conscientiousness", and "agreeableness")

    Avoidant Personality Disorder: Negative Emotion And Detachment
            Wisdom vs Irrationality: N/A
            Courage vs Negative Emotion:
      • Social anxiety (social phobia)
      • Lacks confidence, hypersensitive to rejection
            Helping Others vs Detachment:
      • Social withdrawal, intimacy avoidance, unwilling to get involved with people unless certain of being liked
            Self-Control vs Disinhibition: N/A
            Justice vs Antagonism: N/A

Prevalence

The prevalence of avoidant personality disorder is about 2.4% of the general population.

Course

The course of avoidant personality disorder is chronic. This disorder is usually worse earlier in life and often improves in middle age. This disorder is equally frequent in males and females.

Complications

Individuals with avoidant personality disorder have few close friends, but are very dependent on them. They are described by others as being "shy", "timid," "lonely," and "isolated". Their occupational functioning may also suffer because they avoid social situations that are important for job advancement.

Comorbidity

Personality disorders are an overlooked and underappreciated source of psychiatric morbidity. Comorbid personality disorders may, in fact, account for much of the morbidity attributed to axis I disorders in research and clinical practice. "High percentages of patients with schizotypal (98.8%), borderline (98.3%), avoidant (96.2%), and obsessive-compulsive (87.6%) personality disorder and major depressive disorder (92.8%) exhibited moderate (or worse) impairment or poor (or worse) functioning in at least one area."
Some other disorders frequently occur with this disorder:

    Non-Personality Disorders

            Depressive Disorders:
      • Persistent depressive disorder (dysthymia)
            Anxiety Disorders:
      • Social anxiety disorder (social phobia)

    Personality Disorders

            Negative Emotion Cluster:
      • Dependent personality disorder
          Note: Avoidant and dependent personality disorders are closely related since they both share the same core feature of negative emotion [anxiousness]. If an individual has one of these personality disorders, they are very likely to have the other.
            Detached Cluster:
      • Schizoid personality disorder

Associated Laboratory Findings

No laboratory test has been found to be diagnostic of avoidant personality disorder.

Primate Evolution

There appears to be three different ways in which primates have evolved socially:
  • The chimpanzees have evolved to be socially antagonistic, competitive, callous, and manipulative. Thus chimpanzee social behavior most closely mirrors the antagonistic behavior of the antisocial-narcissistic-borderline-histrionic cluster of personality disorders.

  • In contrast, the bonobos have evolved to be socially anxious, peaceful, cooperative, and loving. Thus bonobo social behavior most closely mirrors the negative emotion (anxious) behavior of the avoidant-dependent cluster of personality disorders.

  • Another separate evolutionary path was followed by the orangutans. They evolved to become solitary hermits. Thus orangutan social behavior most closely mirrors the detached behavior of the paranoid-schizoid-schizotypal cluster of personality disorders.

Core Behaviors Of The Negative Emotion Cluster Of Personality Disorders

Charles Darwin In 1842 With His Eldest Son

Charles Darwin is one of the most influential figures in human history; yet he suffered from avoidant personality disorder. Darwin was eminent as a naturalist, geologist, biologist, and author; and is best known for his explanation of human and animal evolution. However, he so feared public speaking that his friends had to deliver many of his lectures. Likewise, Darwin would not attend public debates of his theories, in that controversy upset him so. For years, he delayed publishing his greatest work, "The Origin Of The Species", because he feared the controversy it would generate. When he died, Darwin was so well-respected that he was buried in Westminster Abbey, close to Isaac Newton. Darwin is an excellent example of how a person can rise above their personality disorder.

The core feature of the avoidant-dependent cluster of personality disorders is negative emotion (anxiousness). Individuals with these disorders suffer from: (1) social anxiety which makes them hypersensitive to rejection/embarrassment (so they avoid relationships), and/or (2) separation anxiety which makes them hypersensitive to separation/loss (so they become overly dependent). In adulthood, if the social anxiety predominates; they develop avoidant personality disorder. If the separation anxiety predominates; they develop panic disorder, depression, or dependent personality disorder.

    Negative Emotion: The Core Feature Of The Negative Emotion Cluster Of Personality Disorders

    • anxiousness:
      Most days in the past week, did you have intense feelings of nervousness, tenseness, or worry?
    • separation insecurity:
      Most days in the past week, did you fear rejection by - or separation from - the significant people in your life?
    • submissiveness:
      Most days in the past week, were you willing to give in to others in a disagreement because you feared their anger or rejection?

Parental Behaviors Which Increase The Risk Of Developing A Personality Disorder

Research has shown that genetic, environmental, and prenatal factors all play important roles in the development of personality disorder. Recent research has also shown that low parental affection and harsh parenting increase the risk of a child later developing a personality disorder.

"Low affection" was defined as: low parental affection, low parental time spent with the child, poor parental communication with the child, poor home maintenance, low educational aspirations for the child, poor parental supervision, low paternal assistance to the child's mother, and poor paternal role fulfillment. "Harsh parenting" was defined as: harsh punishment, inconsistent maternal enforcement of rules, frequent loud arguments between the parents, difficulty controlling anger toward the child, possessiveness, use of guilt to control the child, and verbal abuse.

Setting Goals In Therapy

    Questions To Ask When Setting Goals

    In The Past Week:
    • WHO: was your problem?
    • EVENT: what did he/she do?
    • RESPONSE: how did you respond to that event?
    • OUTCOME: did your response help?
    • TRIGGER: what did you do that could have triggered this problem?
    • GOAL: what life skill(s) do you have to work on? (from checklist)

    Example Of Setting Goals In Interviewing A Person With Avoidant Personality Disorder

    In The Past Week:
    • WHO: was your problem?
      "There's a woman in my office I'd like to date."

    • EVENT: what did he/she do?
      "I tried to ask her out on a date, but before I could ask she had to leave."

    • RESPONSE: how did you respond to that event?
      "I felt so embarrassed that I was at such a loss for words when I was trying to ask her out on a date."

    • OUTCOME: did your response help?
      "No, I hate it when I get embarrassed like that and freeze when I'm talking to a woman. That never happens when I'm talking to my male friends."

    • TRIGGER: what did you do that could have triggered this problem?
      "This is the third time I've botched trying to ask this woman out on a date. Everytime I fail, it gets more difficult."

    • GOAL: what life skill(s) do you have to work on? (from checklist)
      "I want to work on: (1) Self-esteem ("having a good opinion of one’s self and abilities; feeling capable and of worth"), and (2) Assertiveness ("being confident and direct in claiming one’s rights or putting forward one’s views")."

Description



Stories

Free Diagnosis Of This Disorder

Rating Scales


Social Phobia Inventory (SPIN) - online measurement of the severity of social anxiety disorder

Treatment

Research

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