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Avoidant personality disorder
Personality disorder From Wikipedia, the free encyclopedia
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Avoidant personality disorder (AvPD), or anxious personality disorder, is a cluster C personality disorder characterized by excessive social anxiety and inhibition, fear of intimacy (despite an intense desire for it), severe feelings of inadequacy and inferiority, and an overreliance on avoidance of feared stimuli (e.g., self-imposed social isolation) as a maladaptive coping method.[1] 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 despite a strong desire for it.[2] It appears to affect an approximately equal number of men and women.[2]
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 fear of a real or imagined risk of being rejected by the other party.[3]
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 history of abuse or neglect.[4]
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Signs and symptoms
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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, while showing a decreased ability to identify traits within themselves that are generally considered as positive within their societies.[5] Loss and social rejection are so painful that these individuals will choose to be alone rather than risk trying to connect with others.[citation needed] Extreme shyness or anxiety may occur in social situations.[2]
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.[3]
Individuals with the disorder tend to describe themselves as uneasy, anxious, lonely, unwanted and isolated from others.[6] They often choose jobs of isolation in which they do not have to interact with others regularly.[7] Avoidant individuals also avoid performing activities in public spaces for fear of embarrassing themselves in front of others.
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Causes
Causes of AvPD are not clearly defined,[8] but appear to be influenced by a combination of social, genetic and psychological factors. The disorder may be related to temperamental factors that are inherited.[9][10]
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.[11] These inherited characteristics may give an individual a genetic predisposition towards AvPD.[12]
Childhood emotional neglect[13][14][15][16] and peer group rejection[17] are both associated with an increased risk for the development of AvPD.[9] Some researchers believe a combination of high-sensory-processing sensitivity coupled with adverse childhood experiences may heighten the risk of an individual developing AvPD.[18]
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Diagnosis
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Classification
Classification of personality disorders differs significantly between the two most prominent frameworks for classification of mental disorders, namely: the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases, the most recent editions of which are the DSM-5-TR and ICD-11, respectively. While personality disorders, including AvPD, are diagnosed as separate entities in the DSM-5; in the ICD-11 classification of personality disorders, they are assessed in terms of severity levels, with trait and pattern specifiers serving to characterize the particular style of pathology.[19] There is also a hybrid model,[20] called the Alternative DSM-5 model for personality disorders (AMPD), which defines AvPD and five other PDs through disorder-specific combinations of pathological traits and areas of overall impairment.[19]
DSM
The DSM-5 includes two distinct diagnostic models for personality disorder (PD). its main body (Section II) retains a traditional, categorical model of 10 putatively distinct PDs.[19] One of these is AvPD, described as "[a] pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation", operationalized through seven criteria, at least four of which must be met.[2]
The AMPD, contained within Section III of both the DSM-5 and DSM-5-TR as an alternative to the categorical model,[19] defines six specific personality disorders – one of them being AvPD[21] – in terms of a description of the disorder; the characteristic manner in which the disorder impacts personality functioning, i.e. identity, self-direction, empathy and intimacy (criterion A); as well as a listing and description of the pathological personality traits associated with the disorder (criterion B).[22]
At least two of the elements of personality functioning must have a "moderate or greater impairment",[23] manifesting in, for example, the following being true for the identity domain: "[l]ow self-esteem associated with self-appraisal as socially inept, personally unappealing, or inferior; excessive feelings of shame".[19] The AMPD lists the following four pathological traits: anxiousness, withdrawal, anhedonia, and intimacy avoidance;[24] each of these is followed by a description of how the trait manifests in AvPD,[23] such as "reticence in social situations; avoidance of social contacts and activity; [and] lack of initiation of social contact" in the case of withdrawal.[19] A diagnosis requires that three of these traits are present in the subject, with anxiousness being required.[23] Furthermore, additional traits that are can be added as specifiers to the diagnosis.[19] Further requirements, for example relating to differential diagnosis, are embodied in criteria C–G.[20]
ICD
The World Health Organization's ICD-11 has replaced the categorical classification of personality disorders in the ICD-10, in which anxious (avoidant) personality disorder (F60.6) was included as a distinct category,[1] with a dimensional model containing a unified personality disorder (6D10) with severity specifiers, along with specifiers for prominent personality traits or patterns (6D11).[25] Severity is assessed based on the pervasiveness of impairment in several areas of functioning, as well as on the level of distress and harm caused by the disorder,[26] while trait and pattern specifiers are used for recording the manner in which the disturbance is manifested.[7]
Anxious (avoidant) personality disorder has been found to be consistently associated with the ICD-11 trait domains Negative Affectivity (6D11.0) and Detachment (6D11.1),[27] reflecting anxiousness, low self-esteem, and social withdrawal.[27][7] "The complete Avoidant PD pattern of Negative Affectivity and Detachment is overall consistent with the description of Avoidant PD patients as being both fearful and emotionally inhibited".[7] Many studies also report a link to Anankastia (6D11.4), likely due to features such as emotional restraint and excessive caution aimed at avoiding negative outcomes.[27]
Subtypes
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. He identified four adult subtypes of avoidant personality disorder.[28][29]
Others
In 1993, Lynn E. Alden and Martha J. Capreol proposed two other subtypes of avoidant personality disorder:[30]
Differential diagnosis
There is debate as to whether avoidant personality disorder (AvPD) is distinct from social anxiety disorder. Both have similar diagnostic criteria and may share a similar causation, subjective experience, course, treatment and identical underlying personality features, such as shyness.[31][32][33] In contrast to social anxiety disorder, a diagnosis of avoidant personality disorder (AvPD) also requires that the general criteria for a personality disorder be met.[citation needed]
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.[34][35] 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.[35] But they show no differences in social skills or performance on an impromptu speech.[36] Another difference is that social phobia is the fear of social circumstances whereas AvPD is better described as an aversion to intimacy in relationships.[37]
According to the DSM-5, avoidant personality disorder must be differentiated from similar personality disorders such as dependent, paranoid, schizoid, and schizotypal. These can, however, 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.[38][verification needed] There is also an overlap between avoidant and schizoid personality traits and AvPD may have a relationship to the schizophrenia spectrum.[39] Avoidant personality disorder must also be differentiated from autism spectrum disorder.[40]
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Treatment
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Treatment of avoidant personality disorder has been researched only to a minor extent,[41] with a significant portion of the research being derived from studies of social anxiety disorder.[41][24] For AvPD, treatment can employ various techniques, such as social skills training, psychotherapy, cognitive therapy, and exposure treatment to gradually increase social contacts, group therapy for practicing social skills.[41][24] While the use of pharmacotherapy for treatment of AvPD is not known to have been researched, it can be used for treating comorbid conditions and has proven to be useful in treating social anxiety disorder.[41]
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.[42] Significant improvement in the symptoms of personality disorders is possible, with the help of treatment and individual effort.[43]
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Prognosis
Having a personality disorder is usually chronic, and has long-lasting mental conditions.[clarification needed][citation needed] 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.[24]
Epidemiology
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Reported to be at around 1.5%–2.5%, the prevalence of AvPD has also been estimated to be both lower and significantly higher than that.[41] In one study, it was seen in 14.7% of psychiatric outpatients,[44] and its prevalence in clinical settings has been estimated between 5.1 and 55.4%.[45]: 77 It appears to occur with equal frequency in males and females.[2] Some studies indicate a higher prevalence among women.[41]
Comorbidity
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 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.[46] Substance use disorders are also common in individuals with AvPD[41]—particularly in regard to alcohol, benzodiazepines, and opioids[47]—and may significantly affect a patient's prognosis.[48][49]
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.[50] Post-traumatic stress disorder is also commonly comorbid with avoidant personality disorder.[51]
Avoidants are prone to self-loathing and, in certain cases, self-harm.[medical citation needed]
Earlier theorists proposed a personality disorder with a combination of features from borderline personality disorder (BPD) and avoidant personality disorder, called "avoidant-borderline mixed personality" (AvPD/BPD).[52]
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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.[53] Avoidant and schizoid patterns were frequently confused or referred to synonymously until Kretschmer (1921),[54] in providing the first relatively complete description, developed a distinction.[citation needed]
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See also
- Attachment theory
- Avoidance coping
- Counterphobic attitude
- Experiential avoidance
- Inferiority complex
- Sensory processing sensitivity
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References
External links
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