Avoidant personality disorder

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Anxious [avoidant] personality disorder

ICD-10	F606
ICD-9	301.82
OMIM	[1]
DiseasesDB	[2]
MedlinePlus	000940
eMedicine	ped/189
MeSH	{{{MeshNumber}}}

Avoidant personality disorder (sometimes abbreviated APD or AvPD), or anxious personality disorder, is a personality disorder characterized by a pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation and avoiding 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, or disliked. They typically present themselves as loners and report feeling a sense of alienation from society.

Avoidant personality disorder usually is first noticed in early adulthood, and is associated with perceived or actual rejection by parent or peers during childhood. Whether the feeling of rejection is due to the extreme interpersonal monitoring attributed to people with the disorder is still an open question.

Diagnostic criteria (DSM-IV-TR)

The American Psychiatric Association's DSM-IV-TR, a widely used manual for diagnosing mental disorders, defines avoidant personality disorder as a "pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

1. Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection
2. Is unwilling to get involved with people unless certain of being liked
3. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed
4. Is preoccupied with being criticized or rejected in social situations
5. Is inhibited in new interpersonal situations because of feelings of inadequacy
6. Views self as socially inept, personally unappealing, or inferior to others
7. Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing

Avoidant personality disorder is often confused with antisocial personality disorder; clinically the term 'anti-social' denotes sociopathy, not social inhibitions.

Mnemonic

A mnemonic that can be used to remember the criteria for avoidant personality disorder is AVOIDER.

• A – Avoids occupational activities
• V – Views self as socially inept
• O – Occupied with being criticized or rejected
• I – Inhibited in new interpersonal situations
• D – Declines to get involved with people
• E – Embarrassed by engaging in new activities
• R – Refrains from intimate relationships

Link with other mental disorders

Research suggests that people with avoidant personality disorder, in common with social phobics, excessively monitor their own internal reactions when they are involved in social interaction. However, unlike social phobics they also excessively monitor the reactions of the people with whom they are interacting. 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 the people who have a panic disorder with agoraphobia have APD, as well as about 20-40% of the people who have a social phobia (social anxiety disorder). Some studies report prevalence rates of up to 45% among the people with a generalized anxiety disorder and up to 56% of the people with an obsessive-compulsive disorder (Van Velzen, 2002). 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" (APD/BPD) (Kantor, 1993, p.4).

Causes

The cause of avoidant personality disorder is not clearly defined, and may be influenced by a combination of social, genetic, and biological 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.

Many persons diagnosed with avoidant personality disorder have had painful early experiences of chronic parental criticism and rejection. The need to bond with the rejecting parents makes the avoidant person hungry for relationships but their longing gradually develops into a defensive shell of self-protection against repeated parental criticisms.

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 criticism or rejection
• Self-imposed social isolation
• Extreme shyness in social situations, though strongly desire close relationships
• Avoid interpersonal relationships
• Feelings of inadequacy
• Low self-esteem
• Mistrust of others
• Extreme shyness/timidness
• Emotional distancing related to intimacy
• Highly self-conscious
• Self-critical about their problems relating to others
• Problems in occupational functioning
• Lonely self-perception
• Feeling inferior to others
• Chronic substance abuse/dependence
• Creation of a fantasy world

Treatment

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 (Comer, 1996). A key issue in treatment is gaining and keeping the client's trust, since people with APD 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 exaggeratedly negative beliefs about the self (Eckleberry, 2000). While not endorsed by the psychological community, a number of websites have appeared which purport to offer tips to people with avoidant personality disorder^{[How to reference and link to summary or text]}. The main idea which runs through these websites, an idea with which the psychological community would agree, is that persons suffering APD have unrealistically negative views about themselves, and that challenging these beliefs is the first step to overcoming this affliction.

Natural course of the disorder

People with avoidant personality disorder often experience vicious cycles of withdrawal in which the avoidant helps to create the anticipated rejection (Kantor, 1993, Chapter 5). Other people interpret the avoidance of the person with APD as a sign that the avoidant does not like them, and react by avoiding the person. This reinforces the avoidant's fear of rejection and encourages further withdrawal.

Another common development is the appearance of so-called "second-line defenses" in order to deal with the anxiety that the avoidance creates (ibid.). Examples of such defenses are a denial of the fear of rejection, or a replacement of their fear of rejection with a defensive insensitivity. The latter mechanism is called "hardening".

Avoidant PD: History of the disorder

• historical sources
• famous clinicans

Avoidant PD: Epidemiology

• Avoidant PD: Incidence
• Avoidant PD: Prevalence
• Avoidant PD: Morbidity
• Avoidant PD: Mortality
• Avoidant PD: Racial distribution
• Avoidant PD: Age distribution
• Avoidant PD: Sex distribution

Avoidant PD: Risk factors

• Avoidant PD: Known evidence of risk factors
• Avoidant PD: Theories of possible risk factors

Avoidant PD: Etiology

• Avoidant PD: Known evidence of causes
• Avoidant PD: Theories of possible causes

Avoidant PD: Diagnosis & evaluation

• Avoidant PD: Psychological tests
• Avoidant PD: Assessment isssues
• Avoidant PD: Evaluation protocols

Avoidant PD: Treatment

• outcome studies
• Avoidant PD: Treatment protocols
• Avoidant PD: Treatment considerations
• Avoidant PD: Evidenced based treatment
• Avoidant PD: Theory based treatment
• Avoidant PD: Team working considerations
• Avoidant PD: Followup

Avoidant PD: For people with this difficulty

• Avoidant PD: Service user: How to get help
• Avoidant PD: Service user: Self help materials
• Avoidant PD: Service user: Useful reading
• Avoidant PD: Service user: Useful websites
• Avoidant PD: Service user: User feedback on treatment of this condition

Avoidant PD: For their carers

• Avoidant PD: Carer: How to get help
• Avoidant PD: Carer: Useful reading
• Avoidant PD: Carer: Useful websites

Instructions_for_archiving_academic_and_professional_materials Avoidant PD: Academic support materials

• Avoidant PD: Academic: Lecture slides
• Avoidant PD: Academic: Lecture notes
• Avoidant PD: Academic: Lecture handouts
• Avoidant PD: Academic: Multimedia materials
• Avoidant PD: Academic: Other academic support materials
• Avoidant PD: Academic: Anonymous fictional case studies for training

Avoidant PD: For the practitioner

• Avoidant PD: Practitioner: Further reading
• Avoidant PD: Practitioner: Useful websites

Avoidant PD: Anonymous fictional case studies for training

See also

• Shyness
• Love-shyness
• Social anxiety
• Schizoid personality disorder
• Attachment theory
• Solitude
• Recluse
• Hermit
• Hikikomori

Key texts

Books

• Kantor, M. (1993, revised 2003). Distancing: A guide to avoidance and avoidant personality disorder. Westport, Conn: Praeger Publishers.
• Van Velzen, C. J. M. (2002). Social phobia and personality disorders: Comorbidity and treatment issues. Groningen: University Library Groningen. (online version)

Additional material

Books

• Comer, R. J. (1996). Fundamentals of abnormal psychology. Avoidant personality disorder, pp.428-430. Third edition. New York: Worth.

Papers

• Google Scholar
• Rettew, D.C. (2006). "Avoidant Personality Disorder: Boundaries of a Diagnosis", Psychiatric Times, July 1, 2006
• Eckleberry, Sharon C.. Dual Diagnosis and the Avoidant Personality Disorder. The Dual Diagnosis Pages: From Our Desk. URL accessed on 2007-02-06.

External links

• Terry Jones' website about APD

Avoidant Personality Disorder Support Groups and Forums

• http://health.groups.yahoo.com/group/Avoidant/
• http://groups.msn.com/AvoidantPersonalityGroup/
• http://health.groups.yahoo.com/group/AvoidantSanctuary/
• Psych Forums: Avoidant Personality Forum

Information and Support at the Avoidant Personality Disorder Webpages

• http://www.AvoidantPersonality.com

DSM-IV Personality Disorders
Cluster A (Odd) - Schizotypal, Schizoid, Paranoid
Cluster B (Dramatic) - Antisocial, Borderline, Histrionic, Narcissistic
Cluster C (Anxious) - Dependent, Obsessive-Compulsive, Avoidant

de:Selbstunsicher-vermeidende Persönlichkeitsstörung

nl:Ontwijkende persoonlijkheidsstoornis

pl:Osobowość unikająca

pt:Transtorno de personalidade esquiva

sv:Fobisk personlighetsstörning

((enWP|Avoidant personality disorder}}