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Not to be confused with antisocial personality disorder. (Clinically, the term "antisocial" denotes a disregard for society's norms and rules, not social inhibition.)

Avoidant personality disorder (AvPD)^[1] (or anxious personality disorder^[2]) is a personality disorder recognized in the DSM-IV TR handbook in a person over the age of eighteen years as characterized by a pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation, and avoidance of social interaction.

People with AvPD often consider themselves to be socially inept or personally unappealing, and avoid social interaction for fear of being ridiculed, humiliated, rejected, or disliked.

AvPD is usually first noticed in early adulthood, and is associated with perceived or actual rejection by parents or peers during childhood. Whether the feeling of rejection is due to the extreme interpersonal monitoring attributed to people with the disorder is still disputed.

Symptoms

People with AvPD 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 or social anxiety in social situations, though feels a strong desire for close relationships^[3]
• Avoids physical contact because it has been associated with an unpleasant or painful stimulus
• Avoids interpersonal relationships
• Feelings of inadequacy
• Severe low self-esteem
• Self-loathing
• Mistrust of others
• 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
• In some more extreme cases-- Agoraphobia
• Utilizes fantasy as a form of escapism and to interrupt painful thoughts^[4]

Diagnostic criteria (ICD-10)

The World Health Organization's ICD-10 lists avoidant personality disorder as (F60.6) Anxious (avoidant) personality disorder.^[2]

It is characterized by at least 3 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 identified four subtypes of avoidant personality disorder.^[5][6] Any individual avoidant may exhibit none or one of the following:

• conflicted avoidant - including negativistic (passive-aggressive) features

The conflicted avoidant feels ambivalent 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.^[5] They may be perceived as petulant or to be sulking.^[5]

• hypersensitive avoidant - including paranoid features

The hypersensitive avoidant experiences paranoia, mistrustfulness and fear, but to a lesser extent than an individual with paranoid personality disorder.^[5] They may be perceived as petulant or "high-strung".^[6]

• phobic avoidant - including dependent features

• self-deserting avoidant - including depressive features

Differential diagnosis: associated and overlapping conditions

Research suggests that people with AvPD, in common with sufferers of chronic social anxiety disorder (also called social phobia), excessively monitor their own internal reactions when they are involved in social interaction. However, unlike social phobics, people with AvPD may 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 AvPD; they are so preoccupied with monitoring themselves and others that producing fluent speech is difficult.

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 AvPD, 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.^[7] 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 AvPD, called "avoidant-borderline mixed personality" (AvPD/BPD).^[8]

Causes (etiology)

The cause of AvPD is 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.^[9] 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.^[10] These inherited characteristics may give an individual a genetic predisposition towards AvPD.^[11]

Many people diagnosed with AvPD have had painful early experiences of chronic parental and/or societal criticism or rejection. The need to bond with the rejecting parents or peers makes the person with AvPD hungry for relationships, but their longing gradually develops into a defensive shell of self-protection against repeated criticisms.^[3]

Treatment

Treatment of AvPD 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.^[12] A key issue in treatment is gaining and keeping the patient's trust, since people with AvPD 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 AvPD to begin challenging their exaggeratedly negative beliefs about themselves.^[13]

Prevalence (epidemiology)

According to the DSM-IV-TR, AvPD occurs in approximately 0.5% to 1% of the general population.^[14] It is seen in about 10% of psychiatric outpatients.^[15]

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 AvPD in his 1911 work Dementia Praecox: Or the Group of Schizophrenias.^[16] Avoidant and schizoid patterns were frequently confused or referred to synonymously until Kretschmer (1921),^[17] in providing the first relatively complete description, developed a distinction.

See also

Psychology portal

• Attachment theory
• DSM-IV codes (personality disorders)
• Hermit
• Highly sensitive person
• Hikikomori
• ICD-10 codes (personality disorders)
• Inferiority complex
• Love-shyness
• Recluse
• Solitude

References

External links

• Terry L. Jones' website about AvPD
• Chat Room for Avoidants
• Internet Support Group for AvPD
• Psychforums section on AvPD
• SPA: Nonprofit, Free Telephone Support Groups for Avoidant Personality Disorder & other Social Anxiety Problems