Psychiatric Disorders  Article Reprint

Original Article: http://www.psychiatric-disorders.com/articles/personality-disorders/avoidant.php

 

Avoidant Personality Disorder: Too Shy to Function

Many people are shy or nervous in social situations. Normal shyness, despite views sometimes put forward by the popular media, is not a mental disorder. There are, however, clinical conditions in which shyness and social discomfort become so overwhelming that they cross the line between personality type and personality disorder.

Avoidant personality disorder is an example of clinically significant shyness. A personality disorder characterized by extreme social shyness, fear or rejection, and feelings of inadequacy, avoidant personality disorder affects between 2.1 and 2.6 percent of the American adult population, making it one of the most common personality disorders in the US. Without treatment, avoidant people with personality disorders gradually retreat from others, eventually living life in almost complete isolation.

Causes of Avoidant Personality Disorder

A number of possible causes of avoidant personality disorder have been suggested. Unlike many personality disorders, avoidant personal disorder does not appear to have a genetic basis.

Many people with avoidant personality disorder report histories of parental rejection. Some researchers believe that if a child's positive emotions are consistently ignored, criticized, rejected or punished, the child learns to stop expressing those emotions. Similarly, if negative emotions are rejected by parents, the child will come to avoid situations in which negative emotions occur. As negative emotions can occur in almost any social context, this can have a devastating effect on social relationships.

It needs to be noted that not every child who encounters excessive parental rejection develops avoidant personality disorder, suggesting other factors are at work. If parental rejection is accompanied by rejection by a peer group, the risk of avoidant personality disorder is significantly higher, as a broader social group reinforces the family attitudes.

To compound matters even further, many well-meaning advisors and opinion influencers can reinforce the opinion that social avoidance is desirable. Parents, religious leaders, peers, and media, can all deliver the message that avoidant behavior can prevent emotional pain. While these messages have little effect on the general population, they can have a profound effect on people susceptible to avoidant personality disorder.

Signs of Avoidant Personality Disorder

The person suffering from avoidant personality disorder appears shy, timid, and socially ill at ease to observers. The individual is often unusually quiet and may be described as withdrawn or introverted. Speech patterns are often punctuated by long pauses, and speech delivery is slow. Some individuals, on the other hand, may be overly talkative in an attempt to counteract their social discomfort.

Common characteristics of avoidant personality disorder include:
  • avoids or is reluctant to interact socially
  • avoids situations or careers involving social interaction
  • becomes more and more socially isolated over time
  • exaggerates personal difficulties
  • has a fearful preoccupation with making social mistakes
  • has a low self-esteem
  • has no close friends
  • is reluctant to take risks
  • sees own accomplishments as worthless
  • tends to escape into fantasy or daydreams
  • views self as socially inept.

Avoidant Personality Disorder and Relationships

The person suffering from avoidant personality disorder appears shy, timid, and socially ill at ease.People with avoidant personality disorder are preoccupied with fears of social and intimate rejection. As a way to guard against the pain of rejection, some avoidant personality sufferers reject others first, using behavior or insults to drive people away. Rather than aggressive behavior, this is defense behavior for the avoidant personality. If they reject people first, they avoid the pain of being rejected.

Avoidant personality disorder sufferers have other defenses against possible (they might think inevitable) rejection. Some compare people to an impossibly perfect ideal, rejecting anyone who fails to live up to their unattainable high standard. This is another way to reject before being rejected. Others make efforts to interact socially, but avoid close relationships and intimacy, always keeping people at a safe distance.

People with a severe avoidant personality disorder can devise elaborate reasons for avoiding social relationships. These reasons may range from rationalizations ("I'm too busy," "I don't have time") to magical or delusional thinking ("intimacy with others physically damages my heart").

Avoidant Personality Disorder and Social Isolation

Avoidant personality disorder progressively erodes social interaction until those affected by it live in almost complete social isolation. People with the disorder do not desire social isolation; repetitive social failure forces isolation on them. When confronted with real or imagined rejection the individual withdraws socially, a withdrawal that becomes more complete with each progressive rejection or social failure.

Not all of these rejections are imagined. It has been noted that people as emotionally vulnerable as those with avoidant personality disorder seem to attract society's scavengers — people who validate their own worth and self-image by ridiculing others.

Diagnosis of Avoidant Personality Disorder

Diagnosis and treatment are not as problematic for avoidant personality disorder as they are for some other personality disorders. Unlike people with schizoid or paranoid personality disorders, people with avoidant personality disorder are aware that they have a problem, and often genuinely want help. However, the extreme shyness and fear of rejection associated with the disorder prevents many people from seeking treatment.

Diagnosis of avoidant personality disorder requires a detailed history of symptoms, which are then compared to the features of avoidant personality disorder as laid out in the DSM-IV. Patient symptoms must match at least four of the following conditions, as described by the DSM-IV:

  • avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection
  • is unwilling to get involved with people unless certain of being liked
  • shows restraint within intimate relationships because of the fear of being shamed or ridiculed
  • is preoccupied with being criticized or rejected in social situations
  • is inhibited in new interpersonal situations because of feelings of inadequacy
  • views self as socially inept, personally unappealing, or inferior to others
  • is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.

From the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. American Psychiatric Association, 1994.

Differential Diagnosis

Symptoms of avoidant personality disorder are similar to several other disorders, including social anxiety disorders and other personality disorders. These disorders must be ruled out during diagnosis:
  • agoraphobia
  • anxiety disorder
  • chronic substance abuse
  • dependant personality disorder
  • panic disorder
  • paranoid personality disorder
  • schizoid personality disorder
  • schizotypal personality disorder
  • social phobias
  • other underlying medical conditions.

Avoidant Personality Disorder Treatment

Psychotherapy can help people with avoidant personality disorder improve their ability to interact socially. Cognitive-behavioral therapy and assertiveness training may both prove effective. Group therapy, if used carefully and at the right point in treatment, can provide a controlled environment in which to develop social interaction skills.

Fears of rejection by the therapist may cause people with avoidant personality disorder to cease treatment, so patients need to be dealt with carefully by trained professionals, especially during the initial treatment period.

Avoidant personality disorder is one of the few personality disorders that can be treated directly with medication. Antidepressants can partially alleviate social anxiety symptoms. Combinations of therapy and medication seem to be more effective than either treatment alone.

Resources

American Psychiatric Association. Diagnostic criteria for 301.82: Avoidant personality disorder. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. American Psychiatric Association, Washington, DC, 1994.

Ekleberry, S. (2000). Dual diagnosis and the avoidant personality disorder.

Long, P. (nd). Avoidant personality disorder.

National Library of Medicine. (updated 2003). Avoidant personality disorder. MedlinePlus Medical Encyclopedia.

Baier-Barth, L. & Crawford, A. (nd). Avoidant personality disorder.

Rettew, D.C., Jellinek, M.S. & Doyle, A.C. (updated 2004). Personality disorder: Avoidant personality. eMedicine.com.