Avoidant personality disorder (AvPD) is a
Cluster C
Personality disorders (PD) are a class of mental disorders characterized by enduring maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by the individual's culture ...
personality disorder
Personality disorders (PD) are a class of mental disorders characterized by enduring maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by the individual's culture ...
characterized by excessive
social anxiety
Social anxiety is the anxiety and fear specifically linked to being in social settings (i.e., interacting with others). Some categories of disorders associated with social anxiety include anxiety disorders, mood disorders, autism spectrum disord ...
and
inhibition
Inhibitor or inhibition may refer to:
In biology
* Enzyme inhibitor, a substance that binds to an enzyme and decreases the enzyme's activity
* Reuptake inhibitor, a substance that increases neurotransmission by blocking the reuptake of a neurotra ...
,
fear of intimacy
Fear of intimacy is generally a social phobia and anxiety disorder resulting in difficulty forming close relationships with another person. The term can also refer to a scale on a psychometric test, or a type of adult in attachment theory psycholo ...
(despite an intense desire for it), severe feelings of inadequacy and
inferiority
In psychology, an inferiority complex is an intense personal feeling of inadequacy, often resulting in the belief that one is in some way deficient, or inferior, to others.
According to Alfred Adler, a feeling of inferiority may be brought ab ...
, and an overreliance on
avoidance of feared stimuli (e.g. self-imposed
social isolation
Social isolation is a state of complete or near-complete lack of contact between an individual and society. It differs from loneliness, which reflects temporary and involuntary lack of contact with other humans in the world. Social isolation c ...
) as a maladaptive
coping method.
[''Anxious voidant personality disorder' in ICD-10]
Diagnostic Criteria
an
Clinical descriptions and guidelines.
Those affected typically display a pattern of
extreme sensitivity to negative evaluation and
rejection, a belief that one is socially inept or personally unappealing to others, and avoidance of
social interaction
A social relation or also described as a social interaction or social experience is the fundamental unit of analysis within the social sciences, and describes any voluntary or involuntary interpersonal relationship between two or more individuals ...
despite a strong desire for it.
It appears to affect an approximately equal number of men and women.
People with AvPD often avoid social interaction for fear of being ridiculed, humiliated, rejected, or disliked. They typically avoid becoming involved with others unless they are certain they will not be rejected, and may also pre-emptively abandon relationships due to a real or imagined fear that they are at risk of being rejected by the other party.
Childhood emotional neglect (in particular, the rejection of a child by one or both parents) and peer group rejection are associated with an increased risk for its development; however, it is possible for AvPD to occur without any notable history of abuse or neglect.
Signs and symptoms
Avoidant individuals are preoccupied with their own shortcomings and form relationships with others only if they believe they will not be rejected. They often view themselves with
contempt
Contempt is a pattern of attitudes and behaviour, often towards an individual or a group, but sometimes towards an ideology, which has the characteristics of disgust and anger.
The word originated in 1393 in Old French contempt, contemps, ...
, while showing a decreased ability to identify traits within themselves that are generally considered as positive within their societies.
[Will, Retzlaff, ed. (1995). p. 97] Loss and social rejection are so painful that these individuals will choose to be alone rather than risk trying to connect with others.
Some with this disorder fantasize about idealized, accepting and affectionate relationships because of their desire to belong. They often feel themselves unworthy of the relationships they desire, and shame themselves from ever attempting to begin them. If they do manage to form relationships, it is also common for them to pre-emptively abandon them out of fear of the relationship failing.
Individuals with the disorder tend to describe themselves as uneasy, anxious, lonely, unwanted and isolated from others.
They often choose jobs of isolation in which they do not have to interact with others regularly. Avoidant individuals also avoid performing activities in public spaces for fear of embarrassing themselves in front of others.
Symptoms include:
* Extreme
shyness
Shyness (also called diffidence) is the feeling of apprehension, lack of comfort, or awkwardness especially when a person is around other people. This commonly occurs in new situations or with unfamiliar people; a shy person may simply opt t ...
or
anxiety
Anxiety is an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events. Anxiety is different than fear in that the former is defined as the anticipation of a future threat wh ...
in social situations, though the person feels a strong desire for close relationships
* Heightened attachment-related anxiety, which may include a
fear of abandonment
Emotional abandonment is a subjective emotional state in which people feel undesired, left behind, insecure, or discarded. People experiencing emotional abandonment may feel at a loss. They may feel like they have been cut off from a crucial so ...
* Substance use disorders
Comorbidity
AvPD is reported to be especially prevalent in people with
anxiety disorder
Anxiety disorders are a cluster of mental disorders characterized by significant and uncontrollable feelings of anxiety and fear such that a person's social, occupational, and personal function are significantly impaired. Anxiety may cause physi ...
s, although estimates of
comorbidity
In medicine, comorbidity - from Latin morbus ("sickness"), co ("together"), -ity (as if - several sicknesses together) - is the presence of one or more additional conditions often wikt:co-occur#Verb, co-occurring (that is, wikt:concomitant#Adjecti ...
vary widely due to differences in (among others) diagnostic instruments. Research suggests that approximately 10–50% of people who have
panic disorder
Panic disorder is a mental disorder, mental and Abnormal behavior, behavioral disease#Disorder, disorder, specifically an anxiety disorder characterized by reoccurring unexpected panic attacks. Panic attacks are sudden periods of intense fear th ...
with
agoraphobia
Agoraphobia is a mental and behavioral disorder, specifically an anxiety disorder characterized by symptoms of anxiety in situations where the person perceives their environment to be unsafe with no easy way to escape. These situations can in ...
have avoidant personality disorder, as well as about 20–40% of people who have social anxiety disorder. In addition to this, AvPD is more prevalent in people who have comorbid social anxiety disorder and generalised anxiety disorder than in those who have only one of the aforementioned conditions.
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 (OCD) is a mental and behavioral disorder in which an individual has intrusive thoughts and/or feels the need to perform certain routines repeatedly to the extent where it induces distress or impairs general ...
.
Posttraumatic stress disorder
Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that can develop because of exposure to a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on ...
is also commonly comorbid with avoidant personality disorder.
Avoidants are prone to
self-loathing
Self-hatred is personal self-loathing or hatred of oneself, or low self-esteem which may lead to self-harm.
In psychology and psychiatry
The term "self-hatred" is used infrequently by psychologists and psychiatrists, who would usually describe ...
and, in certain cases,
self-harm
Self-harm is intentional behavior that is considered harmful to oneself. This is most commonly regarded as direct injury of one's own skin tissues usually without a suicidal intention. Other terms such as cutting, self-injury and self-mutilatio ...
.
Substance use disorder
Substance use disorder (SUD) is the persistent use of drugs (including alcohol) despite substantial harm and adverse consequences as a result of their use. Substance use disorders are characterized by an array of mental/emotional, physical, and ...
s are also common in individuals with AvPD—particularly in regard to
alcohol
Alcohol most commonly refers to:
* Alcohol (chemistry), an organic compound in which a hydroxyl group is bound to a carbon atom
* Alcohol (drug), an intoxicant found in alcoholic drinks
Alcohol may also refer to:
Chemicals
* Ethanol, one of sev ...
,
benzodiazepine
Benzodiazepines (BZD, BDZ, BZs), sometimes called "benzos", are a class of depressant drugs whose core chemical structure is the fusion of a benzene ring and a diazepine ring. They are prescribed to treat conditions such as anxiety disorders, ...
s, and
opioids
Opioids are substances that act on opioid receptors to produce morphine-like effects. Medically they are primarily used for pain relief, including anesthesia. Other medical uses include suppression of diarrhea, replacement therapy for opioid use ...
—and may significantly affect a patient's prognosis.
Earlier theorists proposed a personality disorder with a combination of features from
borderline personality disorder
Borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD), is a personality disorder characterized by a long-term pattern of unstable interpersonal relationships, distorted sense of self, and strong ...
and avoidant personality disorder, called "avoidant-borderline mixed personality" (AvPD/BPD).
Causes
Causes of AvPD are not clearly defined,
but appear to be influenced by a combination of social, genetic and psychological factors. The disorder may be related to
temperament
In psychology, temperament broadly refers to consistent individual differences in behavior that are biologically based and are relatively independent of learning, system of values and attitudes.
Some researchers point to association of temperam ...
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
A genetic predisposition is a genetic characteristic which influences the possible phenotypic development of an individual organism within a species or population under the influence of environmental conditions. In medicine, genetic susceptibilit ...
towards AvPD.
Childhood emotional neglect and peer group rejection
are both associated with an increased risk for the development of AvPD.
Some researchers believe a combination of high-sensory-processing sensitivity coupled with adverse childhood experiences may heighten the risk of an individual developing AvPD.
Subtypes
Millon
Psychologist
Theodore Millon
Theodore Millon () (August 18, 1928 – January 29, 2014) was an American psychologist known for his work on personality disorders. He founded the ''Journal of Personality Disorders'' and was the inaugural president of the International Society fo ...
notes that because most patients present a mixed picture of symptoms, their
personality disorder
Personality disorders (PD) are a class of mental disorders characterized by enduring maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by the individual's culture ...
tends to be a blend of a major personality disorder type with one or more secondary personality disorder types. He identified four adult subtypes of avoidant personality disorder.
Theodore Millon
Theodore Millon () (August 18, 1928 – January 29, 2014) was an American psychologist known for his work on personality disorders. He founded the ''Journal of Personality Disorders'' and was the inaugural president of the International Society fo ...
(2004): ''Chapter 6 – The Avoidant Personality'' (p.187).
Personality Disorders in Modern Life.
'' Wiley, 2nd Edition. .
Others
In 1993,
Lynn E. Alden and
Martha J. Capreol proposed two other subtypes of avoidant personality disorder:
Diagnosis
ICD
The
World Health Organization
The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of h ...
's
ICD-10
ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs and symptoms, ...
lists avoidant personality disorder as ''anxious (avoidant) personality disorder ()''.
It is characterized by the presence of at least four of the following:
* persistent and pervasive feelings of tension and apprehension;
* belief that one is socially inept, personally unappealing, or inferior to others;
* excessive preoccupation with being criticized or rejected in social situations;
* unwillingness to become involved with people unless certain of being liked;
* restrictions in lifestyle because of need to have physical security;
* 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 all personality disorder diagnoses also satisfy a set of
general personality disorder criteria.
DSM
The
Diagnostic and Statistical Manual of Mental Disorders
The ''Diagnostic and Statistical Manual of Mental Disorders'' (DSM; latest edition: DSM-5-TR, published in March 2022) is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a common langua ...
(DSM) of the
American Psychiatric Association
The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the largest psychiatric organization in the world. It has more than 37,000 members are involve ...
also has an avoidant personality disorder diagnosis (301.82). 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 the following seven specific symptoms should be present:
* Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection
* is unwilling to get involved with people unless 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 risk or to engage in any new activities because they may prove embarrassing
Differential diagnosis
In contrast to
social anxiety disorder
Social anxiety disorder (SAD), also known as social phobia, is an anxiety disorder characterized by sentiments of fear and anxiety in social situations, causing considerable distress and impaired ability to function in at least some aspects ...
, a diagnosis of avoidant personality disorder (AvPD) also requires that the
general criteria for a personality disorder be met.
According to the
DSM-5
The ''Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition'' (DSM-5), is the 2013 update to the ''Diagnostic and Statistical Manual of Mental Disorders'', the taxonomic and diagnostic tool published by the American Psychiatric ...
, avoidant personality disorder must be differentiated from similar personality disorders such as
dependent
A dependant is a person who relies on another as a primary source of income. A common-law spouse who is financially supported by their partner may also be included in this definition. In some jurisdictions, supporting a dependant may enabl ...
,
paranoid
Paranoia is an instinct or thought process that is believed to be heavily influenced by anxiety or fear, often to the point of delusion and irrationality. Paranoid thinking typically includes persecutory beliefs, or beliefs of conspiracy c ...
,
schizoid
Schizoid personality disorder (, often abbreviated as SzPD or ScPD) is a personality disorder characterized by a lack of interest in social relationships, a tendency toward a solitary or sheltered lifestyle, secretiveness, emotional coldness ...
, and
schizotypal
Schizotypal personality disorder (STPD or SPD), also known as schizotypal disorder, is a mental and behavioral disorder. DSM classification describes the disorder specifically as a personality disorder characterized by thought disorder, paran ...
. But these can also occur together; this is particularly likely for AvPD and dependent personality disorder. Thus, if criteria for more than one personality disorder are met, all can be diagnosed.
There is also an overlap between avoidant and schizoid personality traits (see
Schizoid avoidant behavior The relationship between schizoid personality disorder (SPD) and avoidant personality disorder (AvPD) has been a subject of controversy for decades.
Today it is still unclear and remains to be seen if these two personality disorders are genuinely ...
) and AvPD may have a relationship to the
schizophrenia spectrum
A spectrum disorder is a mental disorder that includes a range of linked conditions, sometimes also extending to include singular symptoms and trait theory, traits. The different elements of a spectrum either have a similar appearance or are though ...
.
Avoidant personality disorder must also be differentiated from the
autism spectrum
The autism spectrum, often referred to as just autism or in the context of a professional diagnosis autism spectrum disorder (ASD) or autism spectrum condition (ASC), is a neurodevelopmental condition (or conditions) characterized by difficulti ...
, specifically
Asperger syndrome
Asperger syndrome (AS), also known as Asperger's, is a former neurodevelopmental disorder characterized by significant difficulties in Interpersonal relationship, social interaction and nonverbal communication, along with restricted and re ...
.
Treatment
Treatment of avoidant personality disorder can employ various techniques, such as
social skills training
A social skill is any competence facilitating interaction and communication with others where social rules and relations are created, communicated, and changed in verbal and nonverbal ways. The process of learning these skills is called social ...
,
psychotherapy
Psychotherapy (also psychological therapy, talk therapy, or talking therapy) is the use of psychological methods, particularly when based on regular personal interaction, to help a person change behavior, increase happiness, and overcome pro ...
,
cognitive therapy
Cognitive therapy (CT) is a type of psychotherapy developed by American psychiatrist Aaron T. Beck. CT is one therapeutic approach within the larger group of cognitive behavioral therapies (CBT) and was first expounded by Beck in the 1960s. Cogn ...
, and exposure treatment to gradually increase social contacts,
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. The term can legitimately refer to any form of psychotherapy when delivered in a group format, i ...
for practicing social skills, and sometimes
drug therapy
Pharmacotherapy is therapy using pharmaceutical drugs, as distinguished from therapy using surgery (surgical therapy), radiation (radiation therapy), movement (physical therapy), or other modes. Among physicians, sometimes the term ''medical ther ...
.
A key issue in treatment is gaining and keeping the patient's trust since people with an 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 an avoidant personality disorder to begin challenging their exaggerated negative beliefs about themselves.
Significant improvement in the symptoms of personality disorders is possible, with the help of treatment and individual effort.
Prognosis
Being a personality disorder, which is usually chronic and has long-lasting mental conditions, an avoidant personality disorder may not improve with time without treatment. Given that it is a poorly studied personality disorder and in light of prevalence rates, societal costs, and the current state of research, AvPD qualifies as a neglected disorder.
Controversy
There is debate as to whether avoidant personality disorder (AvPD) is distinct from
social anxiety disorder
Social anxiety disorder (SAD), also known as social phobia, is an anxiety disorder characterized by sentiments of fear and anxiety in social situations, causing considerable distress and impaired ability to function in at least some aspects ...
. Both have similar diagnostic criteria and may share a similar causation, subjective experience, course, treatment and identical underlying personality features, such as
shyness
Shyness (also called diffidence) is the feeling of apprehension, lack of comfort, or awkwardness especially when a person is around other people. This commonly occurs in new situations or with unfamiliar people; a shy person may simply opt t ...
.
It is contended by some that they are merely different conceptualizations of the same disorder, where avoidant personality disorder may represent the more severe form.
In particular, those with AvPD experience not only more severe social phobia symptoms, but are also more depressed and more functionally impaired than patients with generalized social phobia alone.
But they show no differences in social skills or performance on an impromptu speech. Another difference is that social phobia is the ''fear of social circumstances'' whereas AvPD is better described as an ''aversion to intimacy'' in relationships.
Epidemiology
Data from the 2001–02 National Epidemiologic Survey on Alcohol and Related Conditions indicates a
prevalence
In epidemiology, prevalence is the proportion of a particular population found to be affected by a medical condition (typically a disease or a risk factor such as smoking or seatbelt use) at a specific time. It is derived by comparing the number o ...
of 2.36% in the American general population. It appears to occur with equal frequency in males and females.
In one study, it was seen in 14.7% of psychiatric outpatients.
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
Swiss may refer to:
* the adjectival form of Switzerland
* Swiss people
Places
* Swiss, Missouri
* Swiss, North Carolina
*Swiss, West Virginia
* Swiss, Wisconsin
Other uses
*Swiss-system tournament, in various games and sports
*Swiss Internation ...
psychiatrist
Eugen Bleuler
Paul Eugen Bleuler (; ; 30 April 1857 – 15 July 1939) was a Swiss psychiatrist and humanist most notable for his contributions to the understanding of mental illness. He coined several psychiatric terms including "schizophrenia", "schizoid", " ...
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 (, often abbreviated as SzPD or ScPD) is a personality disorder characterized by a lack of interest in social relationships, a tendency toward a solitary or sheltered lifestyle, secretiveness, emotional coldness ...
patterns were frequently confused or referred to synonymously until
Kretschmer (1921),
in providing the first relatively complete description, developed a distinction.
See also
*
Attachment theory
Attachment theory is a psychological, evolutionary and ethological theory concerning relationships between humans. The most important tenet is that young children need to develop a relationship with at least one primary caregiver for normal ...
*
Avoidance coping
In psychology, avoidance coping is a coping mechanism and form of experiential avoidance. It is characterized by a person's efforts, conscious or unconscious, to avoid dealing with a stressor in order to protect oneself from the difficulties the s ...
*
Counterphobic attitude
Counterphobic attitude is a response to anxiety that, instead of fleeing the source of fear in the manner of a phobia, actively seeks it out, in the hope of overcoming the original anxiousness.
Contrary to the avoidant personality disorder, the co ...
*
Experiential avoidance
Experiential avoidance (EA) has been broadly defined as attempts to avoid thoughts, feelings, memories, physical sensations, and other internal experiences—even when doing so creates harm in the long run. The process of EA is thought to be mainta ...
*
Inferiority complex
In psychology, an inferiority complex is an intense personal feeling of inadequacy, often resulting in the belief that one is in some way deficient, or inferior, to others.
According to Alfred Adler, a feeling of inferiority may be brought ab ...
*
Sensory processing sensitivity
Sensory processing sensitivity (SPS) is a temperamental or personality trait involving "an increased sensitivity of the central nervous system and a deeper cognitive processing of physical, social and emotional stimuli". The trait is characteri ...
Social:
*
Hermit
A hermit, also known as an eremite (adjectival form: hermitic or eremitic) or solitary, is a person who lives in seclusion. Eremitism plays a role in a variety of religions.
Description
In Christianity, the term was originally applied to a Ch ...
* ''
Hikikomori
, also known as acute social withdrawal, is total withdrawal from society and seeking extreme degrees of social isolation and confinement. ''Hikikomori'' refers to both the phenomenon in general and the recluses themselves. ''Hikikomori'' ha ...
''
*
Loner
A loner is a person who does not seek out, or may actively avoid, interaction with other people. There are many potential reasons for their solitude. Intentional reasons include introversion, mysticism, spirituality, religion, or personal consid ...
*
Recluse
A recluse is a person who lives in voluntary seclusion from the public and society. The word is from the Latin ''recludere'', which means "shut up" or "sequester". Historically, the word referred to a Christian hermit's total isolation from th ...
*
Solitude
Solitude is a state of seclusion or isolation, meaning lack of socialisation. Effects can be either positive or negative, depending on the situation. Short-term solitude is often valued as a time when one may work, think, or rest without distu ...
* ''
Taijin kyofusho
''Taijin kyofusho'' ( ja, 対人恐怖症, TKS, for ''taijin kyofusho symptoms'') is a Japanese culture-specific syndrome. The term taijin kyofusho translates into the disorder (sho) of fear (kyofu) of interpersonal relations (taijin). Those who h ...
''
References
External links
{{Authority control
Cluster C personality disorders