Avoidant personality disorder

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Overview
Avoidant personality disorder (APD or AvPD) or Anxious personality disorder (APD), is a personality disorder characterized by a pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation and avoidance of 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,rejected 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 disputed.

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, ridiculed, or rejected
 * 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 a disregard for society's norms and rules, not social inhibitions.

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 psychological 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 people 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 feels a strong desire for close relationships
 * Avoids interpersonal relationships
 * Feelings of inadequacy
 * Low self-esteem
 * Mistrust of others
 * Extreme shyness/timidity
 * 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
 * Investment in fixed fantasies

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 patient'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).

Additional Resources

 * Comer, R. J. (1996). Fundamentals of abnormal psychology. Avoidant personality disorder, pp.428-430. Third edition. New York: Worth.
 * Kantor, M. (1993, revised 2003). Distancing: A guide to avoidance and avoidant personality disorder. Westport, Conn: Praeger Publishers.
 * Rettew, D.C. (2006). "Avoidant Personality Disorder: Boundaries of a Diagnosis", Psychiatric Times, July 1, 2006
 * Van Velzen, C. J. M. (2002). Social phobia and personality disorders: Comorbidity and treatment issues. Groningen: University Library Groningen. (online version
 * Van Velzen, C. J. M. (2002). Social phobia and personality disorders: Comorbidity and treatment issues. Groningen: University Library Groningen. (online version

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