Avoidant personality disorder
Avoidant personality disorder (sometimes abbreviated APD or AvPD) is a personality disorder characterised by a pervasive pattern of social inhibition, feelings of inadequacy, and extreme sensitivity to negative evaluation. People with avoidant personality disorder often consider themselves to be socially inept or personally unappealing, and avoid social interaction for fear of being ridiculed or humiliated.
Avoidant personality disorder usually is first noticed in early adulthood, and is associated with rejection during childhood by parents and peers. Whether the rejection is due to the extreme interpersonal monitoring attributed to people with the disorder is still an open question.
Diagnostic criteria (DSM-IV-TR)
The DSM-IV-TR, a widely used manual for diagnosing mental disorders (see also: DSM cautionary statement), 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 or ridiculed
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.
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. 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).
Natural course of the disorder
After some time, people with avoidant personality disorder often experience vicious cycles of withdrawal in which the avoidant helps to create the anticipated rejection (Kantor, 1993, Chapter 5). Other people interpret the avoidance of the person with APD as a sign that the avoidant does not like them, and react by avoiding the person. This reinforces the avoidant's fear of rejection and encourages further withdrawal.
Another common development is the appearance of so-called "second-line defenses" in order to deal with the anxiety that the avoidance creates (ibid.). Examples of such defenses are a denial of the fear of rejection, or a replacement of their fear of rejection with a defensive insensitivity. The latter mechanism is called "hardening".
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 client's trust, since people with APD will often start to avoid treatment sessions if they distrust the therapist or fear rejection.
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