Avoidant Personality Disorder

Avoidant Personality Disorder

Definition

Avoidant personality disorder (AVPD) is a pervasive pattern of timidity, inhibition, inadequacy and social hypersensitivity (American Psychiatric Association, 2000). Persons with AVPD may have a strong desire to develop close, personal relation-ships but feel too insecure to approach others or to express their feelings. AVPD is indicated by the presence of four or more of the seven diagnostic criteria presented in the DSM criteria for AVPD.

Etiology and Pathology

AVPD appears to be an extreme variant of the fundamental person-ality traits of introversion and neuroticism. Introversion includes such facets as passivity, social withdrawal and inhibition, while neuroticism includes self-consciousness, vulnerability and anx-iousness. The personality dimensions of neuroticism and introver-sion have substantial heritability, as do the more specific traits of social anxiousness and shyness.

In childhood, neuroticism appears as a distress-prone or inhibited temperament. Shyness, timidity and interper-sonal insecurity might be exacerbated further in childhood through overprotection and excessive cautiousness. Parental behavior coupled with a distress-prone temperament has been shown to result in social inhibition and timidity. Most children and adolescents will have many experiences of interpersonal embarrassment, rejection, or humiliation, but these will be particularly devastating to the person who is already lacking in self-confidence or is temperamentally passive, inhibited, or introverted.

AVPD may involve elevated peripheral sympathetic activity and adrenocortical responsiveness, resulting in excessive autonomic arousal, fearfulness and inhibition (Siever and Davis, 1991). Just as ASPD may involve deficits in the functioning of a behavioral inhibition system, AVPD may involve excessive functioning of this same. The pathology of AVPD, however, may also be more psychological than neurochemical, with the timid-ity, shyness and insecurity being a natural result of a cumulative history of denigrating, embarrassing and devaluing experiences. Underlying AVPD may be excessive self-consciousness, feelings of inadequacy or inferiority, and irrational cognitive schemas that perpetuate introverted, avoidant behavior.

Differential Diagnosis

The most difficult differential diagnosis for AVPD is with gen-eralized social phobia. Both involve an avoidance of social situa-tions, social anxiety and timidity, and both may be evident since late childhood or adolescence. Many persons with AVPD in fact seek treatment for a social phobia. To the extent that the behavior pattern pervades the person’s everyday functioning and has been evident since childhood, the diagnosis of a personality disorder would be more descriptive. There are arguments to subsume all cases of AVPD into the diagnosis of generalized social phobia (as was done for schizoid disorder of childhood in DSM-IV-TR) but there is considerable empirical support for the existence of the personality dimensions of introversion and neuroticism and for an understanding of AVPD as a maladaptive variant of these personality traits.

Many persons with AVPD may also meet the criteria for dependent personality disorder (DPD). This might at first glance seem unusual, given that AVPD involves social withdrawal whereas DPD involves excessive social attachment. Howeveronce a person with AVPD is able to obtain a relationship, he or she will often cling to this relationship in a dependent man-ner. Both disorders include feelings of inadequacy, needs for reassurance and hypersensitivity to criticism and neglect (i.e. abnormally high levels of anxiousness, self-consciousness and vulnerability). A distinction between AVPD and DPD is best made when the person is seeking a relationship. Avoidant per-sons tend to be very shy, inhibited and timid (and are therefore slow to get involved with someone) whereas dependent persons urgently seek another relationship as soon as one ends (i.e., avoidant persons are high in introversion whereas dependent persons are high in extraversion). Avoidant persons may also be reluctant to express their feelings whereas dependent persons can drive others away by continuous expressions of neediness. The differentiation of AVPD from the schizoid, paranoid and schizotypal personality disorders was discussed in previous sections.

Epidemiology and Comorbidity

Timidity, shyness and social insecurity are not uncommon prob-lems and AVPD is one of the more prevalent personality disor-ders within clinical settings, occurring in 5 to 25% of all patients (American Psychiatric Association, 2000). However, AVPD may be diagnosed in only 1 to 2% of the general population. It appears to occur equally among males and females, with some studies reporting more males and others reporting more females. Persons with AVPD are likely to have symptoms that meet the DSM-IV criteria for a generalized social phobia, and others may have a mood disorder.

Course

Persons with AVPD are shy, timid and anxious as children. Many are diagnosed with a social phobia during childhood. Adoles-cence is a particularly difficult developmental period due to the importance at this time of attractiveness, dating and popularity. Occupational success may not be significantly impaired, as long as there is little demand for public performance. Persons with AVPD may in fact find considerable gratification and esteem through a job or career that they are unable to find within their relationships. The job may serve as a distraction from intense feelings of loneliness. Their avoidance of social situations will impair their ability to develop adequate social skills, and this will then further handicap any eventual efforts to develop relation-ships. As parents, they may be very responsible, empathic and affectionate, but may unwittingly impart feelings of social anx-iousness and awkwardness. Severity of the AVPD symptomatol-ogy diminishes as the person becomes older.

Treatment

Persons with AVPD seek treatment for their avoidant personal-ity traits, although many initially seek treatment for symptoms of anxiety, particularly social phobia (generalized subtype). It is important in such cases to recognize that the shyness is not due simply to a dysregulation or dyscontrol of anxiousness. There is instead a more pervasive and fundamental psychopathology, involving feelings of interpersonal insecurity, low self-esteem and inadequacy.

Social skills training, systematic desensitization and a graded hierarchy of in vivo exposure to feared social situa-tions have been shown to be useful in the treatment of AVPD. However, it is also important to discuss the underlying fears and insecurities regarding attractiveness, desirability, rejection or intimacy. Persons with AVPD are at times reluctant to dis-cuss such feelings, as they may feel embarrassed, they may fear being ridiculed, or they may not want to “waste the time” of the therapist with such “foolish” insecurities. They may prefer a less revealing or involved form of treatment. It is important to be understanding, patient and accepting, and to proceed at a pace that is comfortable for the patient. Inse-curities and fears can at times be addressed through cogni-tive techniques as the irrationality is usually readily apparent. It remains useful though to identify the historical source of their development as this understanding will help the patient appreciate the irrationality or irrelevance of their expectations and perceptions for their current relationships.

Persons with AVPD often find group therapies to be help-ful. Exploratory and supportive groups can provide them with an understanding environment in which to discuss their social insecurities, to explore and practice more assertive behaviors, and to develop an increased self-confidence to approach others and to develop relationships outside of the group. Focused and specialized social skills training groups would be preferable to unstructured groups that might be predominated by much more assertive and extraverted members.

Many persons with AVPD will respond to anxiolytic medications, and at times to antidepressants, particularly such monoamine oxidase inhibitors as phenelzine. Normal and abnormal feelings of anxiousness can be suppressed or dimin-ished through pharmacologic interventions. This approach may in fact be necessary to overcome initial feelings of intense so-cial anxiety that are markedly disruptive to current functioning (e.g., inability to give required presentations at work or to talk to new acquaintances). However, it is also important to moni-tor closely a reliance on medications. Persons with AVPD could be prone to rely excessively on substances to control their feel-ings of anxiousness, whereas their more general feelings of in-security and inadequacy would require a more comprehensive treatment.