Avoidant personality disorder

Not to be confused with Antisocial personality disorder.
Anxious [avoidant] personality disorder
Classification and external resources
Specialty Psychiatry
ICD-10 F60.6
ICD-9-CM 301.82
MedlinePlus 000940
eMedicine ped/189
MeSH D010554

Avoidant personality disorder (AvPD), also known as anxious personality disorder,[1] is a Cluster C personality disorder. Those affected display a pattern of social inhibition, feelings of inadequacy and inferiority, extreme sensitivity to negative evaluation, and avoidance of social interaction despite a strong desire to be close to others.[2] Individuals with the disorder tend to describe themselves as uneasy, anxious, lonely, unwanted and isolated from others.[3] The behavior typically begins by early adulthood, and occurs across a variety of situations.[4]

The cause is unknown.[5] It is recognized by the Diagnostic and Statistical Manual of Mental Disorders.[4]

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. As the name suggests, the main coping mechanism of those with avoidant personality disorder is avoidance of feared stimuli.[1] Avoidant personality disorder is usually first noticed in early adulthood, with both childhood emotional neglect—in particular, the rejection of a child by one or both parents—and peer group rejection being associated with an increased risk for its development.[6]

Signs and symptoms

Those with this disorder may often choose jobs of isolation so that they do not have to interact with the public regularly, due to their anxiety and fear of embarrassing themselves in front of others. Some with this disorder may fantasize about idealized, accepting, and affectionate relationships, due to their desire to belong. They often feel themselves unworthy of the relationships they desire, so they shame themselves from ever attempting the relationship.[7]

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 alone rather than risk trying to connect with others. They often view themselves with contempt,[3] while showing an increased inability to identify traits within themselves that are generally considered as positive within their societies.[8]

Causes

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 temperamental factors that are inherited.[12][13] 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.[14] These inherited characteristics may give an individual a genetic predisposition towards avoidant personality disorder.[15] Childhood emotional neglect[16][17][18][19] and peer group rejection[10] are both associated with an increased risk for the development of avoidant personality disorder.[12]

Millon's subtypes

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.[20] He identified four adult subtypes of avoidant personality disorder.[21]

Subtype Features
Phobic (including dependent features) General apprehensiveness displaced with avoidable tangible precipitant; qualms and disquietude symbolized by repugnant and specific dreadful object or circumstances.
Conflicted (including negativistic features) Internal discord and dissension; fears dependence; unsettled; unreconciled within self; hesitating, confused, tormented, paroxysmic, embittered; unresolvable angst.
Hypersensitive (including paranoid features) Intensely wary and suspicious; alternately panicky, terrified, edgy, and timorous, then thin-skinned, high-strung, petulant, and prickly.
Self-deserting (including depressive features) Blocks or fragments self awareness; discards painful images and memories; casts away untenable thoughts and impulses; ultimately jettisons self (suicidal).[20]

Diagnosis

World Health Organization

The World Health Organization's ICD-10 lists avoidant personality disorder as (F60.6) anxious (avoidant) personality disorder.[1] It is characterized by at least four of the following:[22]

  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.

American Psychiatric Association

The DSM-5 also has an Avoidant Personality Disorder diagnosis. 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 seven specific symptoms should be present, which are the following:[2]

  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 risk or to engage in any new activities because they may prove embarrassing

Other

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).[23]

Differential diagnosis

In contrast to social anxiety disorder, a diagnosis of avoidant personality disorder also requires that the general criteria for a personality disorder are met. Another difference is that social phobia is the fear of social circumstances whereas AvPD is better described as an aversion to intimacy in relationships.[24]

According to the Diagnostic and Statistical Manual of Mental Disorders, avoidant personality disorder must be differentiated from dependent, paranoid, schizoid, and schizotypal personality disorders.[25] There is, however, an overlap between avoidant and schizoid personality traits (see Schizoid avoidant behavior) and AVPD may have a relationship to the Schizophrenia spectrum.[26]

Comorbidity

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 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, avoidant personality disorder is more prevalent in persons who have comorbid social anxiety disorder and generalised anxiety disorder than in those who have only one of the aforementioned conditions.[27]

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.[28]

Treatment

Treatment of avoidant personality disorder can employ various techniques, such as social skills training, cognitive therapy, and exposure treatment to gradually increase social contacts, group therapy for practicing social skills, and sometimes drug therapy.[29] 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.[30]

Significant improvement in the symptoms of personality disorders is possible, with the help of treatment and individual effort.[31]

Controversy

There is controversy as to whether avoidant personality disorder is a distinct disorder from generalized social anxiety disorder, 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.[32][33] In particular, in addition to having more severe social phobia symptoms, patients with avoidant personality disorder are more depressed and have more functional impairment than patients with only generalized social phobia[33] but show no differences in social skills or performance on an impromptu speech.[34] Generalized social anxiety disorder and avoidant personality disorder have similar diagnostic criteria and may share a similar causation, subjective experience, course and treatment and identical underlying personality features, such as shyness.[35][36][37]

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.[38] It appears to occur with equal frequency in males and females.[2] In one study, it was seen in 14.7% of psychiatric outpatients.[39]

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.[40] Avoidant and schizoid patterns were frequently confused or referred to synonymously until Kretschmer (1921),[41] in providing the first relatively complete description, developed a distinction.

See also

Social:

References

  1. 1 2 3 "Anxious [avoidant] personality disorder". International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10). Retrieved 19 February 2015.
  2. 1 2 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.
  3. 1 2 Millon, Theodore; Davis, Roger D. (1996). Disorders of Personality: DSM-IV and Beyond, 2nd Edition. p. 263.
  4. 1 2 Diagnostic and statistical manual of mental disorders : DSM-5 (5th ed.). Washington [etc.]: American Psychiatric Publishing. 2013. p. 645. ISBN 9780890425558.
  5. ↑ Sederer, Lloyd I. (2009). Blueprints psychiatry (5th ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins. p. 29. ISBN 9780781782531.
  6. ↑ "Avoidant Personality Disorder - Environmental Factors".
  7. ↑ Hoeksema, Nolen (2014). Abnormal Psychology (6th ed.). McGraw Education. p. 275. ISBN 9781308211503.
  8. ↑ Will, Retzlaff, ed. (1995). p. 97
  9. ↑ Gary Gilles M.A.; Paula Ford-Martin M.A. (2003). "Avoidant personality disorder". Avoidant personality disorder. Healthline Networks. Retrieved 2006-02-26.
  10. 1 2 Sperry, Len (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.
  11. ↑ Avoidant Personality Disorder, Real Mental Health, Inc.
  12. 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 2774890Freely accessible. PMID 19583885.
  13. ↑ 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.
  14. ↑ Suzanne M. Sutherland, M.D. (2006). "Avoidant Personality Disorder Causes, Frequency, Siblings and Mortality — Morbidity". Avoidant Personality Disorder. Armenian Medical Network. Retrieved 2007-02-26.
  15. ↑ Lenzenweger, Mark F.; Clarkin, John F. (2005). Major Theories of Personality Disorder. Guilford Press. p. 69. ISBN 1-59385-108-1.
  16. ↑ 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.
  17. ↑ 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.
  18. ↑ 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.
  19. ↑ 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.
  20. 1 2 Millon, Theadore. "Personality Subtypes Summary". http://www.millon.net. Institute for Advanced Studies in Personology and Psychopathology. Retrieved 8 January 2013. External link in |work= (help)
  21. ↑ Millon, Theodore (2004). Personality Disorders in Modern Life. John Wiley & Sons, Inc., Hoboken, New Jersey. ISBN 0-471-23734-5.
  22. ↑ WHO.int
  23. ↑ Kantor, M. (1993, revised 2003). Distancing: A Guide to Avoidance and Avoidant Personality Disorder. Westport, Conn: Praeger Publishers.
  24. ↑ Comer, R. J. (2007). Abnormal Psychology Seventh Edition. New York, NY: Worth Publishers.
  25. ↑ American Psychiatric Association. (2000). "Anxiety disorders." In Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev., pp. 450–456). Washington, D.C.: American Psychiatric Association.
  26. ↑ Fogelson DL; Nuechterlein KH; Asarnow RA; et al. (March 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: 192–199. doi:10.1016/j.schres.2006.12.023. PMC 1904485Freely accessible. PMID 17306508.
  27. ↑ "Prevalence of personality disorders among patients with anxiety disorders". ScienceDirect. 51: 167–174. doi:10.1016/0165-1781(94)90036-1. Retrieved 7 September 2015.
  28. ↑ Van Velzen, C. J. M. (2002). Social Phobia and Personality Disorders: Comorbidity and Treatment Issues. Groningen: University Library Groningen. (online version)
  29. ↑ Comer, R. J. (1996). Fundamentals of Abnormal Psychology. Avoidant personality disorder, pp. 428–430. Third edition. New York: Worth.
  30. ↑ 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.
  31. ↑ "Personality Disorder - Treatment". Mind. Retrieved 5 February 2016.
  32. ↑ 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.
  33. 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.
  34. ↑ 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.
  35. ↑ Ralevski, E.; Sanislow, C. A.; Grilo, C. M.; Skodol, A. E.; Gunderson, J. G.; Tracie Shea, M.; Yen, S.; Bender, D. S.; 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.
  36. ↑ 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.
  37. ↑ 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.
  38. ↑ 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.
  39. ↑ 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.
  40. ↑ Millon, Theodore; Martinez, Alexandra (1995). "Avoidant Personality Disorder". In Livesley, W. John. The DSM-IV Personality Disorders. Guilford Press. p. 218. ISBN 0-89862-257-3.
  41. ↑ Kretschmer, Ernst (1921). Körperbau und Charakter. J. Springer.
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