Avoidant Personality

Shyness And Social Anxiety System

Treating Social Phobias and Social Anxiety

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Avoidant personality, or Avoidant Personality Disorder (APD), is a label included in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association to describe a condition in which a person

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 of potential embarrassment (DSM-IV, 1994, pp. 664-665)

Avoidant Personality Disorder is found in approximately 1% of the general population and in 10% of individuals seeking outpatient treatment from mental health clinics. This personality pattern occurs equally in men and women. Although APD can begin when people are in their teens, many avoidant individuals report that they have been socially anxious for as long as they can remember. Individuals with APD commonly display a variety of other clinical disorders, in particular, the anxiety disorders, mood disorders, and schizophrenic-spectrum disorders. Empirical studies also indicate that between 15% and 30% of people who abuse alcohol meet the criteria for APD, which suggests that long-standing social avoidance may increase vulnerability to substance dependence.

Personality types characterized by social sensitivity and withdrawal appear in earlier clinical descriptions of personality disorders; however, contemporary views of avoidant personality disorder have their origins in Theodore Millon's biosocial learning theory. In his book Disorders of Personality (1981), Millon proposed that the avoidant pattern develops when a child with a fearful or anxious temperament is exposed to early social experiences characterized by persistent deprecation, rejection, and humiliation. Avoidant individuals learn what Millon labeled an active-detached coping pattern. This consists of behavioral strategies designed to protect the person from the painful emotions he or she expects to result from interpersonal encounters.

Cognitive and interpersonal models of APD have also been developed. In their book Cognitive Therapy of Personality Disorders (1990), Aaron Beck and Arthur Freeman emphasized the role of cognitive schemas that develop in response to traumatic early social experiences and/or biological sensitivities. According to these writers, schemas—the cognitive structures that organize experience—include beliefs and rules of conduct, which for the avoidant person take such forms as "If people get close to me they will reject me" and "Don't stick your neck out." Although accurate in an historical sense, these schemas are hypothesized to lead to distortions in processing current social information and to the adoption of maladaptive interpersonal strategies.

Interpersonal writers emphasize the contribution of self-perpetuating transactional cycles to the onset and maintenance of APD. According to these writers, early social experiences lead avoidant individuals to develop beliefs about people that color their interpretations of current interactions. As a result, they adopt behaviors that provoke negative reactions from others, thereby confirming their original beliefs. In short, people with APD are caught in a cycle of unwittingly reenacting the early significant relationships that led to the development of their underlying fears. Consistent with all of these theories, research indicates that childhood maltreatment, particularly neglect, increases the likelihood that a person will develop APD.

There are similarities between APD and personality traits such as shyness and behavioral inhibition. The primary distinction is that APD is characterized by greater distress and impairment. Shyness and behavioral inhibition have been shown to arise in part from innate differ ences in physiological reactivity to environmental change. This suggests that individuals with APD either have stronger biological dispositions toward anxiety than do shy people or have experienced more negative social developmental events that exacerbate innate biological vulnerabilities.

Avoidant Personality Disorder also shares features with several other clinical conditions, most notably generalized Social Phobia (GSP) and Dependent Personality Disorder (DPD). A substantial number of individuals with APD also meet diagnostic criteria for GSP, and as many as 60% of patients with GSP meet criteria for APD. Comparative studies indicate that patients with APD report greater social anxiety and depression and lower self-esteem, and they display more comorbid diagnoses than do patients with GSP alone, but few other differences emerge. Avoidant Personality Disorder also overlaps with DPD. Research suggests that only the symptom of social withdrawal reliably discriminates the two conditions, and in practice, diagnoses of APD and DPD often co-occur. Distinctions between APD, GSP, and DPD require further study.

A variety of treatment strategies for APD have been evaluated, including cognitive-behavioral, interpersonal, and pharmacological regimens. Empirical studies show that behavioral and cognitive-behavioral treatment programs produce significant improvement in social comfort and activity in avoidant individuals and may be more effective than psychodynamic therapies. Overall, psychological treatments produce significant gains in avoidant patients, and these gains are maintained, at least over the year following treatment termination. On a less positive note, many APD individuals remain at the low end or below normative levels of social functioning even after treatment. This suggests that avoidant individuals may require a longer course of treatment or that biological factors or early trauma limit change. Pharmacological regimens have also been examined, primarily in the context of treating patients with Social Phobia. The monoamine oxidase inhibitors (MAOIs), particularly phenelzine, and the serotonin-reuptake inhibitors (SRIs) are considered the most effective pharmacological interventions presently available. Even patients who respond to medication, however, can continue to have some problems with social avoidance, and further work on the treatment of this long-standing condition is required.

SUGGESTED READING

Alden, L. E., Laposa, J. M., Taylor, C. T., & Ryder, A. G. (2002). Avoidant personality disorder: Current status and future directions. Journal of Personality Disorders, 16, 1-29. Beck, A. T., & Freeman, A. (1990). Cognitive therapy of Personality

Disorders. New York: Guilford Press. Millon, T. (1981). Disorders of Personality, DSM-III: Axis II. New York: Wiley Interscience.

Lynn Alden

University of British Columbia, Vancouver, Canada See also: Shyness

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