Avoidant Personality Disorder

AVOIDANT PERSONALITY DISORDER

Clinical Picture

Avoidant personality disorder is characterized by a pervasive pattern of social discomfort and reticence, low self-esteem, and hypersensitivity to negative evaluation. It occurs in 0.5% to 1% of the general population and in 10% of the clinical population. It is equally common in men and women. Clients are good candidates for indi-vidual psychotherapy (APA, 2000).

These clients are likely to report being overly inhib-ited as children and that they often avoid unfamiliar situations and people with an intensity beyond that expected for their developmental stage. This inhibi-tion, which may have continued throughout upbring-ing, contributes to low self-esteem and social alien-ation. Clients are apt to be anxious and may fidget in chairs and make poor eye contact with the nurse. They may be reluctant to ask questions or to make requests. They may appear sad as well as anxious. They describe being shy, fearful, socially awkward, and easily devas-tated by real or perceived criticism. Their usual response to these feelings is to become more reticent and withdrawn.

Clients have very low self-esteem. They are hypersen-sitive to negative evaluation from others and readily believe themselves to be inferior. Clients are reluctant to do anything perceived as risky, which, for them, is almost anything. They are fearful and convinced they will make a mistake, be humiliated, or embarrass themselves and others. Because they are unusually fearful of rejection, criticism, shame, or disapproval, they tend to avoid situ-ations or relationships that may result in these feelings. They usually strongly desire social acceptance and human companionship: they wish for closeness and inti-macy but fear possible rejection and humiliation. These fears hinder socialization, which makes clients seem awkward and socially inept and reinforces their beliefs about themselves. They may need excessive reassurance of guaranteed acceptance before they are willing to risk forming a relationship.

Clients may report some success in occupational roles because they are so eager to please or to win a supervisor’s approval. Shyness, awkwardness, or fear of failure, how-ever, may prevent them from seeking jobs that might be more suitable, challenging, or rewarding. For example, a client may reject a promotion and continue to remain in an entry-level position for years even though he or she is well qualified to advance.

Nursing Interventions

These clients require much support and reassurance from the nurse. In the nonthreatening context of the relationship, the nurse can help them to explore posi-tive self-aspects, positive responses from others, and possible reasons for self-criticism. Helping clients to practice self-affirmations and positive self-talk may be useful in promoting self-esteem. Other cognitive restruc-turing techniques such as reframing and decatastrophiz-ing (described previously) can enhance self-worth. The nurse can teach social skills and help clients to practice them in the safety of the nurse–client relationship. Although these clients have many social fears, those are often counterbalanced by their desire for meaningful social contact and relationships. The nurse must be careful and patient with clients and not expect them to implement social skills too rapidly.