Overview
Avoidant Personality Disorder is characterized by social inhibition marked by an avoidance of social settings and activities, along with an inescapable feeling of inferiority. As a Cluster C Personality Disorder, its prevailing symptoms are based in fear and anxiety. It is increasingly difficult for these individuals to participate in social settings, which has negative consequences on their performance at the workplace, interpersonal relationships, as well as daily functioning, and causes significant levels of psychological distress.
A female preponderance is reported in some studies, while an even distribution among males and females is otherwise considered among its prevalence. Avoidant Personality Disorder is often attributed to factors such as temperament, genetics, childhood experiences, and attachment styles. The emphasis is on the interaction of these dynamics and their resultant influence.
Treatment for the disorder is based largely in non-pharmacological modes, including forms of behavioral therapy and psychodynamic therapy. There is little evidence for the efficiency of pharmacological alternatives.
Signs and Symptoms
The signs and symptoms of Avoidant Personality Disorder include:
- Persistently feeling inferior, inadequate or โnot good enoughโ
- Being isolated and lacking close personal friends
- Reluctance to meet new people or enter social settings
- Being overly sensitive to and fearing criticism
- Feelings of loneliness and boredom
- Extreme anxiety upon contacting people
- Being overly self-conscious
- Being extremely critical of oneself
- Shyness and being quiet and removed from social settings
- Reacting strongly to subtleties or jokes that may resemble mockery
- Fear of vulnerability
- Reluctance to take personal risks
- Avoiding participating in new activities for the fear of embarrassment upon failing
- Difficulty with intimacy
- Being restrained when talking about oneself
- Withholding emotions
- Living a restricted lifestyle
- Over exaggerating the dangers associated with situations
- Being careful and vigilant with regards to the movements and expressions of others
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Risk Factors
While some studies report a female predominance in the prevalence of Avoidant Personality Disorder, others do not. Prominent shyness in children is said to become more severe with age among individuals with Avoidant Personality Disorder. Additional demographic factors such as being single, unemployment, low levels of education, poor health, greater visits to the hospital, mental distress, and a generally low quality of life have been associated with Avoidant Personality Disorder.
The aetiology of Avoidant Personality Disorder largely focuses on early childhood experiences, genetic components, temperament, and attachment styles.
Early interactions with parents or caregivers, as well as experiences of abuse and neglect are linked with the presentation of Avoidant Personality Disorder. Patients reportedly thought of their caregivers as less affectionate, rejecting, less encouraging, and to be instigating feelings of guilt.
The development of hypervigilance as a way of coping with neglect and turbulent caregiving has also been postulated as a correlate, with the hypervigilance then spreading into other interpersonal relations. On the other hand, it has also been hypothesized that the negative experiences with caregivers give rise to the tendency to expect distress and rejection from social settings, thus making the individual avoid those interactions altogether.
A modest genetic component has been highlighted by twin studies, which indicated a stable heritable component in the occurrence of Avoidant Personality Disorder. Moreover, certain trait aspects such as fear of negative evaluation, introversion, and neurotic tendencies are also considered to be moderately heritable.
Temperamental liabilities include factors such as rigidity, sensitivity, and harm avoidance not only act as potential correlates, but possibly also increase the effect of negative childhood experiences and have an impact on the methods of coping engaged in by the individual.
Anxious/avoidant attachment styles, which exhibit avoidant tendencies, detachedness, and dismissal, as well as fearful attachment styles, often put across as involving the desire for intimacy in spite of an inability to trust others and be afraid of rejection have been linked with the disorder.
These considered correlates do not function independently in the aetiology of the disorder, and it is their interaction with each other that is considered to increase the risk of Avoidant Personality Disorder. A genetic predisposition to certain temperaments combined with the perception of negative experiences during childhood, influenced and affecting attachment styles can bring about avoidant tendencies.
Diagnosis
A diagnosis of Avoidant Personality Disorder may be based on clinical evaluations, administration of particular scales or questionnaires, and the fulfilment of diagnostic criteria.
The DSM-5 lists the following diagnostic criteria for Avoidant Personality Disorder:
There is a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation that starts in early adulthood and is present in various contexts, as shown by four or more of the following:
- Avoiding occupational activities involving significant interpersonal contact due to a fear of criticism, disapproval, or rejection.
- Unwillingness to get involved with people unless certain of being liked
- Restraint in intimate relationships due to the fear of being shamed or ridiculed
- Preoccupation with being criticized/rejected in social situations
- Inhibition is new interpersonal settings due to feelings of inadequacy
- Viewing self as socially inept, personally unappealing, or inferior to others
- Unusual reluctance to take personal risks or to engage in any new activity as it may lead to embarrassment
Avoidant Personality Disorder is often associated with Schizoid Personality Disorder and Social Anxiety Disorder (Social Phobia) due to the similarity in the presentation of symptomatology among the disorders.
While Schizoid Personality shares the isolation component with Avoidant Personality Disorder, it is important to note that the latter involves a desire for intimacy and to form interpersonal relationships while the former does not. Schizoid personality presents with cold and aloof behavior, along with an indifference to criticism as well as a high risk of psychosis.
The overlap with Social Anxiety Disorder, on the other hand, makes the two disorders more difficult to distinguish between. Both disorders may occur as comorbidities, which causes a substantial increase in the distress caused, as well as higher levels of impairment. While there was once dispute about whether Avoidant Personality Disorder required a diagnosis of its own or if it could be considered as a more severe manifestation of Social Phobia, multifactorial differences have kept the two diagnoses discrete.
Treatment
While there is a paucity of treatment aligned research in the case of Avoidant Personality Disorder, methods of management have been inferred from successful approaches used in the treatment of Social Anxiety Disorder.
Much of the case-study based as well as empirical evidence outlining effective treatment of Avoidant Personality Disorder demonstrates the efficacy of psychotherapeutic approaches to management. This involves a variety of methods including Cognitive Behavioral Therapy, social skills training, schema therapy, psychodynamic treatment, and group therapy.
Cognitive Behavioral Therapy in the treatment of Avoidant Personality Disorder was initially carried out in group settings and involved activities that pursued gradual exposure, systemic desensitization, role play, working on self-image, and social skills training.
Subsequently, utilization of cognitive models such as finding and reversing core beliefs (in the case of Avoidant Personality Disorder, for e.g., the belief that โpeople will reject me if they get to know meโ), developing adaptive ways of thinking to reduce negative thoughts and replacing maladaptive behaviors, became more prevalent.
Schema Therapy targets momentary cognitions, emotions and behaviors that have formed due to unmet needs and have led to certain coping styles. In the case of Avoidant Personality Disorder, the focus is on feelings of loneliness and unworthiness, coping styles based in avoidance, reluctance to voice or express inner needs, as well as the reversal of the belief that one needs to punish or blame themselves.
While there is no evidence suggesting the effectiveness of pharmacotherapy in treating Avoidant Personality Disorder, in accordance with following management styles for social phobia, antidepressants such as MAOIs (Monoamine Oxidase Inhibitors) and SSRIs (Selective Serotonin Reuptake Inhibitors) may be of help.
A problem-focused approach is suggested in the management of the disorder, with the selection of treatment being driven by the individualistic experience and presentation of symptomatology and history.ย
Differential Diagnosis
1. Anxiety disorders: The symptoms of social anxiety disorder and agoraphobia are overlapping to the extent that they often co-occur or are understood to be the same condition with different names.
2. Other personality disorders: Many personality disorders have common features with avoidant personality disorder. Some of those being paranoid personality disorder, dependent personality disorder and schizoid personality disorder. However, the basic cause of avoidant personality disorder is to prevent humiliation in public settings.ย
3. Personality change due to medical condition: Various medical conditions can have an effect on the central nervous system and trigger a change in personality. This change may be similar to avoidant personality disorder, but the onset of the change proves to be the distinguishing factor.
Specialists
Psychiatrists or Clinical Psychologists may be involved in the diagnostic procedure for Antisocial Personality Disorder. Based on the appropriate choice of intervention upon thorough assessment, specialists who can implement the chosen form of therapy, such as Cognitive Behavioral Therapy practitioners, may be involved in the treatment process.
In Conclusion
Extreme self-critiquing can be harmful to oneโs self-esteem. It is natural to feel intimidated at one point or another, but when it becomes a prolonged feeling and turns into crippling insecurity then it causes issues in social, personal, and professional life. Although treatment will not entirely cure the condition, it will gradually help in reducing the symptoms.
Therapy for Avoidant Personality Disorder includes behavioral therapy that may help reduce the anxiety and stress that comes with the inferiority complex.
The signs can be observed in childhood and adolescence and if not treated properly, this can turn into severe social anxiety.
Our professionals at Ananda provide personalized therapy and help in the reversal of the condition.
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