Avoidant personality disorder

Avoidant personality disorder (AvPD)<noinclude>, or anxious personality disorder,</noinclude> is <noinclude>a personality disorder </noinclude>characterized by excessive social anxiety and inhibition, fear of intimacy (despite an intense desire for it), severe feelings of inadequacy and inferiority, and an overreliance on avoidance of feared stimuli (e.g., self-imposed social isolation) as a maladaptive coping method. Those affected typically display a pattern of extreme sensitivity to negative evaluation and rejection, a belief that one is socially inept or personally unappealing to others, and avoidance of social interaction despite a strong desire for it.

Signs and symptoms

Avoidant individuals are preoccupied with their own shortcomings and form relationships with others only if they believe they will not be rejected. They often view themselves with contempt, while showing a decreased ability to identify traits within themselves that are generally considered as positive within their societies. Extreme shyness or anxiety may occur in social situations.

Individuals with the disorder tend to describe themselves as uneasy, anxious, lonely, unwanted and isolated from others. They often choose jobs of isolation in which they do not have to interact with others regularly. but appear to 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been associated with a temperament characterized by behavioral inhibition, including features of being shy, fearful and withdrawn in new situations. These inherited characteristics may give an individual a genetic predisposition towards AvPD.

Childhood emotional neglect and peer group rejection are both associated with an increased risk for the development of AvPD. Some researchers believe a combination of high-sensory-processing sensitivity coupled with adverse childhood experiences may heighten the risk of an individual developing AvPD.

Diagnosis

Classification

Classification of personality disorders differs significantly between the two most prominent frameworks for classification of mental disorders, namely: the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases, the most recent editions of which are the DSM-5-TR and ICD-11, respectively. While personality disorders, including AvPD, are diagnosed as separate entities in the DSM-5; in the ICD-11 classification of personality disorders, they are assessed in terms of severity levels, with trait and pattern specifiers serving to characterize the particular style of pathology. There is also a hybrid model, called the Alternative DSM-5 model for personality disorders (AMPD), which defines AvPD and five other PDs through disorder-specific combinations of pathological traits and areas of overall impairment. AvPD is described as "[a] pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation", operationalized through seven criteria, at least four of which must be met. This system of classification has several limitations, such as each category capturing a heterogeneous set of presentations. – in terms of a description of the disorder; the characteristic manner in which the disorder impacts personality functioning, i.e. identity, self-direction, empathy and intimacy (criterion A); as well as a listing and description of the pathological personality traits associated with the disorder (criterion B).

At least two of the elements of personality functioning must have a "moderate or greater impairment", manifesting in, for example, the following being true for the identity domain: "[l]ow self-esteem associated with self-appraisal as socially inept, personally unappealing, or inferior; excessive feelings of shame". Severity is assessed based on the pervasiveness of impairment in several areas of functioning, as well as on the level of distress and harm caused by the disorder, while trait and pattern specifiers are used for recording the manner in which the disturbance is manifested.thumb|398x398px|This ICD-11 case profile could belong to a person eligible for ICD-10 avoidant and [[Dependent personality disorder|dependent PD diagnoses. In contrast to social anxiety disorder, a diagnosis of avoidant personality disorder (AvPD) also requires that the general criteria for a personality disorder be met.

It is contended by some that they are merely different conceptualizations of the same disorder, where avoidant personality disorder may represent the more severe form. In particular, those with AvPD experience not only more severe social phobia symptoms, but are also more depressed and more functionally impaired than patients with generalized social phobia alone. Another difference is that social phobia is the fear of social circumstances whereas AvPD is better described as an aversion to intimacy in relationships.

Another personality disorder diagnosis could be more suitable for a presentation considered for a diagnosis of AvPD; however, these can also be diagnosed alongside AvPD, provided that the requirements for diagnosis are met for all of them (see ). Specific features may indicate which diagnosis of several is the most suitable. Social isolation is also a prominent feature of schizoid and schizotypal PDs; the significant difference between these and AvPD is that people with the former disorders may not experience discomfort stemming from it, whereas people with AvPD are likely to suffer from this isolation. Moreover, there are differences in what gives rise to the "feelings of inadequacy, hypersensitivity to criticism, and [...] need for reassurance" that AvPD shares with dependent personality disorder; while people with the former disorder worry excessively about being rejected and humiliated, those with the latter disorder experience a need of nurturance. Lastly, "reluctance to confide in others", which is also a feature of paranoid PD, "is attributable more to a fear of being embarrassed or being found inadequate than to a fear of others' malicious intent", as in the latter disorder. Avoidant personality disorder must also be differentiated from autism spectrum disorder.

Subtypes

Millon's subtypes

Psychologist Theodore Millon notes that because most patients present a mixed picture of symptoms, their personality disorder tends to be a blend of a major personality disorder type with one or more secondary personality disorder types. He identified four adult subtypes of avoidant personality disorder.

{| class="wikitable"

! Subtype

!Features

! Traits

| Phobic avoidant

|Including dependent features

| General apprehensiveness displaced with avoidable tangible precipitant; qualms and disquietude symbolized by a repugnant and specific dreadful object or circumstances.

| Conflicted avoidant

|Including negativistic features

| Internal discord and dissension; fears dependence; unsettled; unreconciled within self; hesitating, confused, tormented, paroxysmic, embittered; unresolvable angst.

| Hypersensitive avoidant

|Including paranoid features

| Intensely wary and suspicious; alternately panicky, terrified, edgy, and timorous, then thin-skinned, high-strung, petulant, and prickly.

| Self-deserting avoidant

|Including depressive features

| Blocks or fragments self-awareness; discards painful images and memories; casts away untenable thoughts and impulses; possibly suicidal.

{| class="wikitable"

! Subtype

! Characteristics

| Cold-avoidant

| Characterised by an inability to experience and express positive emotion towards others.

| Exploitable-avoidant

| Characterised by an inability to express anger towards others or to resist coercion from others. May be at risk for abuse by others.

Treatment

Treatment of avoidant personality disorder has been researched only to a minor extent, Significant improvement in the symptoms of personality disorders is possible, with the help of treatment and individual effort.

Prognosis

Having a personality disorder is usually chronic, and has long-lasting mental conditions. An avoidant personality disorder may not improve with time without treatment. Given that it is a poorly studied personality disorder and in light of prevalence rates, societal costs, and the current state of research, AvPD qualifies as a neglected disorder.

Epidemiology

Reported to be at around 1.5%–2.5%, the prevalence of AvPD has also been estimated to be both lower and significantly higher than that. In one study, it was seen in 14.7% of psychiatric outpatients, and its prevalence in clinical settings has been estimated between 5.1 and 55.4%. It appears to occur with equal frequency in males and females. Substance use disorders are also common in individuals with AvPD—and may significantly affect a patient's prognosis.

Some studies report prevalence rates of up to 45% among people with generalized anxiety disorder and up to 56% of those with obsessive–compulsive disorder. Post-traumatic stress disorder and dependent personality disorder are also commonly comorbid with avoidant personality disorder.

History

The avoidant personality has been described in several sources as far back as the early 1900s, although it was not so named for some time. Swiss psychiatrist Eugen Bleuler described patients who exhibited signs of avoidant personality disorder in his 1911 work Dementia Praecox: Or the Group of Schizophrenias. Avoidant and schizoid patterns were frequently confused or referred to synonymously until Kretschmer (1921), in providing the first relatively complete description, developed a distinction.

References

External links

Alternative DSM-5 Model for Personality Disorders (with AMPD definition of AvPD)