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Avoidant personality disorder

Avoidant personality disorder

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Avoidant personality disorder (or anxious personality disorder) is a personality disorder
Personality disorder
Personality disorders, formerly referred to as character disorders, are a class of personality types and behaviors. Personality disorders are noted on Axis II of the Diagnostic and Statistical Manual of Mental Disorders or DSM-IV-TR of the American Psychiatric Association.Personality disorders are...

 recognized in the Diagnostic and Statistical Manual of Mental Disorders
Diagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...

 handbook in a person characterized by a pervasive pattern of social inhibition
Social inhibition
Social inhibition is a conscious or subconscious constraint by a person of behaviour of a social nature. The constraint may be in relation to behavior, appearance, or a subject matter for discussion, besides other matters. There are a number of reasons for social inhibitions, including that the...

, feelings of inadequacy, extreme sensitivity to negative evaluation, and avoidance of social interaction
Interpersonal relationship
An interpersonal relationship is an association between two or more people that may range from fleeting to enduring. This association may be based on limerence, love, solidarity, regular business interactions, or some other type of social commitment. Interpersonal relationships are formed in the...

.

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
Social anxiety disorder
Social anxiety disorder , also known as social phobia, is an anxiety disorder characterized by intense fear in social situations causing considerable distress and impaired ability to function in at least some parts of daily life...

 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 as 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.

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
Switzerland
Switzerland name of one of the Swiss cantons. ; ; ; or ), in its full name the Swiss Confederation , is a federal republic consisting of 26 cantons, with Bern as the seat of the federal authorities. The country is situated in Western Europe,Or Central Europe depending on the definition....

 psychiatrist Eugen Bleuler
Eugen Bleuler
Paul Eugen Bleuler was a Swiss psychiatrist most notable for his contributions to the understanding of mental illness and for coining the term "schizophrenia."-Biography:...

 described patients who exhibited signs of avoidant personality disorder in his 1911 work Dementia Praecox: Or the Group of Schizophrenias. Avoidant and schizoid
Schizoid personality disorder
Schizoid personality disorder is a personality disorder characterized by a lack of interest in social relationships, a tendency towards a solitary lifestyle, secretiveness, emotional coldness, and sometimes apathy, with a simultaneous rich, elaborate, and exclusively internal fantasy world...

 patterns were frequently confused or referred to synonymously until Kretschmer
Ernst Kretschmer
Ernst Kretschmer Prof. Dr. med. Dr. phil. h.c., was a German psychiatrist who researched the human constitution and established a typology...

 (1921), in providing the first relatively complete description, developed a distinction.

Signs and symptoms


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.
  • Hypersensitivity to rejection
    Social rejection
    Social rejection occurs when an individual is deliberately excluded from a social relationship or social interaction. The topic includes both interpersonal rejection and romantic rejection. A person can be rejected on an individual basis or by an entire group of people...

    /criticism
    Criticism
    Criticism is the judgement of the merits and faults of the work or actions of an individual or group by another . To criticize does not necessarily imply to find fault, but the word is often taken to mean the simple expression of an objection against prejudice, or a disapproval.Another meaning of...

  • Self-imposed social isolation
    Social isolation
    Social isolation refers to a lack of contact with society for members of social species. There may be many causes and individuals in numerous generally social species are isolated at times, it need not be a pathological condition. In human society, in those cases where it is viewed as a pathology,...

  • Extreme shyness
    Shyness
    In humans, shyness is a social psychology term used to describe the feeling of apprehension, lack of comfort, or awkwardness experienced when a person is in proximity to, approaching, or being approached by other people, especially in new situations or with unfamiliar people...

     or anxiety
    Social anxiety
    Social anxiety is anxiety about social situations, interactions with others, and being evaluated or scrutinized by other people...

     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-esteem
    Self-esteem is a term in psychology to reflect a person's overall evaluation or appraisal of his or her own worth. Self-esteem encompasses beliefs and emotions such as triumph, despair, pride and shame: some would distinguish how 'the self-concept is what we think about the self; self-esteem, the...

  • Self-loathing
  • Mistrust
    Mistrust
    Mistrust means "to doubt, to lack confidence in". It does not necessarily imply any serious suspicion of malice or bad faith.This can happen in everyday life in situations where the parties otherwise trust each other, but find themselves questioning that trust...

     of others
  • Emotional distancing
    Personal boundaries
    Personal boundaries are guidelines, rules or limits that a person creates to identify for him- or herself what are reasonable, safe and permissible ways for other people to behave around him or her and how he or she will respond when someone steps outside those limits.'Personal boundaries define...

     related to intimacy
  • Highly self-conscious
  • Self-critical
    Self-criticism
    Self-criticism refers to the pointing out of things critical/important to one's own beliefs, thoughts, actions, behaviour or results; it can form part of private, personal reflection or a group discussion.-Philosophy:...

     about their problems relating to others
  • Problems in occupational functioning
  • Lonely self-perception, although others may find the relationship with them meaningful
  • Feeling inferior
    Inferiority complex
    An inferiority complex, in the fields of psychology and psychoanalysis, is a feeling that one is inferior to others in some way. Such feelings can arise from an imagined or actual inferiority in the afflicted person...

     to others
  • In some more extreme cases — agoraphobia
    Agoraphobia
    Agoraphobia is an anxiety disorder defined as a morbid fear of having a panic attack or panic-like symptoms in a situation from which it is perceived to be difficult to escape. These situations can include, but are not limited to, wide-open spaces, crowds, or uncontrolled social conditions...

  • Utilizes fantasy
    Fantasy (psychology)
    Fantasy in a psychological sense is broadly used to cover two different senses, conscious and unconscious. In the unconscious sense, it is sometimes spelled "phantasy".-Conscious fantasy:...

     as a form of escapism
    Escapism
    Escapism is mental diversion by means of entertainment or recreation, as an "escape" from the perceived unpleasant or banal aspects of daily life...

     and to interrupt painful thoughts

Causes


Apart from the above, other 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 temperament
Temperament
In psychology, temperament refers to those aspects of an individual's personality, such as introversion or extroversion, that are often regarded as innate rather than learned...

al 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
Genetic predisposition
A genetic predisposition is a genetic affectation which influences the phenotype of an individual organism within a species or population but by definition that phenotype can also be modified by the environmental conditions. In the rest of the population, conditions cannot have that effect...

 towards AvPD.Childhood emotional neglect and peer group rejection are both associated with an increased risk for the development of AvPD.

World Health Organization


The World Health Organization
World Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...

's ICD-10
ICD-10
The International Statistical Classification of Diseases and Related Health Problems, 10th Revision is a medical classification list for the coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases, as maintained by the...

 lists avoidant personality disorder as anxious (avoidant) personality disorder. It is characterized by at least four of the following:
  1. persistent and pervasive feelings of tension and apprehension;
  2. belief that one is socially inept, personally unappealing, or inferior to others;
  3. excessive preoccupation with being criticized or rejected in social situations;
  4. unwillingness to become involved with people unless certain of being liked;
  5. restrictions in lifestyle because of need to have physical security;
  6. 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 a diagnosis of any specific personality disorder also satisfy a set of general personality disorder criteria.

Millon's subtypes


Psychologist Theodore Millon
Theodore Millon
Theodore Millon is an American psychologist known for his work on personality disorders.-Biography:Millon was born in 1928, the only child of immigrant Jewish parents from Lithuania and Poland. His 19th-century ancestors came from the town of Valozhyn, then a part of the Russian Empire...

 identified four subtypes of avoidant personality disorder. Any individual avoidant may exhibit none or one of the following:
  • conflicted avoidant - including negativistic features
The conflicted avoidant feels ambivalent
Ambivalence
Ambivalence is a state of having simultaneous, conflicting feelings toward a person or thing. Stated another way, ambivalence is the experience of having thoughts and/or emotions of both positive and negative valence toward someone or something. A common example of ambivalence is the feeling of...

 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.
  • hypersensitive avoidant - including paranoid
    Paranoid personality disorder
    Paranoid personality disorder is a psychiatric diagnosis characterized by paranoia and a pervasive, long-standing suspiciousness and generalized mistrust of others....

     features
The hypersensitive avoidant experiences paranoia
Paranoia
Paranoia [] is a thought process believed to be heavily influenced by anxiety or fear, often to the point of irrationality and delusion. Paranoid thinking typically includes persecutory beliefs, or beliefs of conspiracy concerning a perceived threat towards oneself...

, mistrustfulness and fear, but to a lesser extent than an individual with paranoid personality disorder
Paranoid personality disorder
Paranoid personality disorder is a psychiatric diagnosis characterized by paranoia and a pervasive, long-standing suspiciousness and generalized mistrust of others....

. They may be perceived as petulant or "high-strung".
  • phobic avoidant - including dependent
    Dependent personality disorder
    Dependent personality disorder , formerly known as asthenic personality disorder, is a personality disorder that is characterized by a pervasive psychological dependence on other people...

     features

  • self-deserting avoidant - including depressive
    Depressive personality disorder
    Depressive Personality Disorder is a controversial psychiatric diagnosis that denotes a personality disorder with depressive features....

     features

Differential diagnosis


Research suggests that people with avoidant personality disorder, in common with sufferers of chronic social anxiety disorder
Social anxiety disorder
Social anxiety disorder , also known as social phobia, is an anxiety disorder characterized by intense fear in social situations causing considerable distress and impaired ability to function in at least some parts of daily life...

 (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 disorder
Anxiety disorder
Anxiety disorder is a blanket term covering several different forms of abnormal and pathological fear and anxiety. Conditions now considered anxiety disorders only came under the aegis of psychiatry at the end of the 19th century. Gelder, Mayou & Geddes explains that anxiety disorders are...

s, although estimates of comorbidity
Comorbidity
In medicine, comorbidity is either the presence of one or more disorders in addition to a primary disease or disorder, or the effect of such additional disorders or diseases.- In medicine :...

 vary widely due to differences in (among others) diagnostic instruments. Research suggests that approximately 10–50% of people who have panic disorder
Panic disorder
Panic disorder is an anxiety disorder characterized by recurring severe panic attacks. It may also include significant behavioral change lasting at least a month and of ongoing worry about the implications or concern about having other attacks. The latter are called anticipatory attacks...

 with agoraphobia
Agoraphobia
Agoraphobia is an anxiety disorder defined as a morbid fear of having a panic attack or panic-like symptoms in a situation from which it is perceived to be difficult to escape. These situations can include, but are not limited to, wide-open spaces, crowds, or uncontrolled social conditions...

 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
Obsessive-compulsive disorder
Obsessive–compulsive disorder is an anxiety disorder characterized by intrusive thoughts that produce uneasiness, apprehension, fear, or worry, by repetitive behaviors aimed at reducing the associated anxiety, or by a combination of such obsessions and compulsions...

. 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
Borderline personality disorder
Borderline personality disorder is a personality disorder described as a prolonged disturbance of personality function in a person , characterized by depth and variability of moods.The disorder typically involves unusual levels of instability in mood; black and white thinking, or splitting; the...

 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


Treatment of avoidant personality disorder can employ various techniques, such as social skills training, cognitive therapy
Cognitive therapy
Cognitive behavioral therapy is a psychotherapeutic approach: a talking therapy. CBT aims to solve problems concerning dysfunctional emotions, behaviors and cognitions through a goal-oriented, systematic procedure in the present...

, exposure treatment to gradually increase social contacts, group therapy
Group therapy
Group psychotherapy or group therapy is a form of psychotherapy in which one or more therapists treat a small group of clients together as a group...

 for practicing social skills, and sometimes drug therapy
Pharmacology
Pharmacology is the branch of medicine and biology concerned with the study of drug action. More specifically, it is the study of the interactions that occur between a living organism and chemicals that affect normal or abnormal biochemical function...

. 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.

Epidemiology


According to the DSM-IV-TR, avoidant personality disorder occurs in approximately 0.5% to 1% of the general population. However, data from the 2001-02 National Epidemiologic Survery on Alcohol and Related Conditions indicates a prevalence rate of the disorder of 2.36% in the American general population. It is seen in about 10% of psychiatric outpatients.

See also


  • Attachment theory
    Attachment theory
    Attachment theory describes the dynamics of long-term relationships between humans. Its most important tenet is that an infant needs to develop a relationship with at least one primary caregiver for social and emotional development to occur normally. Attachment theory is an interdisciplinary study...

  • Hermit
    Hermit
    A hermit is a person who lives, to some degree, in seclusion from society.In Christianity, the term was originally applied to a Christian who lives the eremitic life out of a religious conviction, namely the Desert Theology of the Old Testament .In the...

  • Highly sensitive person
    Highly sensitive person
    A highly sensitive person is a person having the innate trait of high psychological sensitivity . According to Elaine N...

  • Hikikomori
    Hikikomori
    is a Japanese term to refer to the phenomenon of reclusive people who have chosen to withdraw from social life, often seeking extreme degrees of isolation and confinement because of various personal and social factors in their lives...

  • Inferiority complex
    Inferiority complex
    An inferiority complex, in the fields of psychology and psychoanalysis, is a feeling that one is inferior to others in some way. Such feelings can arise from an imagined or actual inferiority in the afflicted person...

  • Loner
    Loner
    A loner is a person who avoids or does not actively seek human interaction or prefers to be alone. There are many reasons for solitude, intentional or otherwise, and "loner" implies no specific cause. Intentional reasons include spiritual and religious considerations or personal philosophies...

  • Love-shyness
    Love-shyness
    - The Definition Of Love-shyness:Love-shyness is a specific type of severe chronic shyness that impairs or prevents intimate relationships. It implies a degree of inhibition and reticence with potential partners that is sufficiently severe to preclude participation in courtship, marriage and family...

  • Recluse
    Recluse
    A recluse is a person who lives in voluntary seclusion from the public and society, often close to nature. The word is from the Latin recludere, which means "shut up" or "sequester." There are many potential reasons for becoming a recluse: a personal philosophy that rejects consumer society; a...

  • Solitude
    Solitude
    Solitude is a state of seclusion or isolation, i.e., lack of contact with people. It may stem from bad relationships, deliberate choice, infectious disease, mental disorders, neurological disorders or circumstances of employment or situation .Short-term solitude is often valued as a time when one...

  • Taijin kyofusho
    Taijin kyofusho
    Taijin kyofusho , is a Japanese culture-specific syndrome. The term taijin kyofusho literally means the disorder of fear of interpersonal relations . Dr...