Avoidant personality disorder

Many people diagnosed with AvPD have had painful early experiences of chronic
parental and/or societal criticism or rejection. The need to bond with the rejecting parents
or peers makes the person with AvPD hungry for relationships, but their longing
gradually develops into a defensive shell of self-protection against repeated criticisms.

I swear I'll never be such a father for my children.

Not to be confused with antisocial personality disorder. (Clinically, the term "antisocial"
denotes a disregard for society's norms and rules, not social inhibition.)

Avoidant personality disorder (AvPD)[1] (or anxious personality disorder[2]) is a

personality disorder recognized in the DSM-IV TR handbook in a person over the age of
eighteen years as characterized by a pervasive

pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative

evaluation, and avoidance of social interaction.
People with AvPD often consider themselves to be socially inept or personally
unappealing, and avoid social interaction for fear of being ridiculed, humiliated,
rejected, or disliked.

AvPD is usually first noticed in early adulthood, and is associated with perceived or
actual rejection by parents or peers during childhood. Whether the feeling of rejection is
due to the extreme interpersonal monitoring attributed to people with the disorder is still
disputed.

People with AvPD are preoccupied with their own shortcomings and form relationships
with others only if they believe they will not be rejected. Loss and rejection are so painful
that these individuals will choose to be lonely rather than risk trying to connect with
others.

• Hypersensitivity to criticism or rejection

• Self-imposed social isolation
• Extreme shyness or social anxiety in social situations, though feels a strong desire
for close relationships[4]
• Avoids physical contact because it has been associated with an unpleasant or
painful stimulus
• Avoids interpersonal relationships
• Feelings of inadequacy
• Severe low self-esteem
• Self-loathing
• Mistrust of others
• Emotional distancing related to intimacy
• Highly self-conscious
• Self-critical about their problems relating to others
• Problems in occupational functioning
 • Lonely self-perception
• Feeling inferior to others
• In some more extreme cases-- Agoraphobia
• Utilizes fantasy as a form of escapism and to interrupt painful thoughts[5]

Differential diagnosis: associated and overlapping

conditions
Research suggests that people with AvPD, in common with chronic social anxiety
sufferers also called 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 AvPD; they are so preoccupied with monitoring
themselves and others that producing fluent speech is difficult.

AvPD 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 people who have panic
disorder with agoraphobia have AvPD, as well as about 20–40% of people who have
social phobia (social anxiety disorder).

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.[8] 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 AvPD,
called "avoidant-borderline mixed personality" (AvPD/BPD).[9]

Many people diagnosed with AvPD have had painful early experiences of chronic
parental and/or societal criticism or rejection. The need to bond with the rejecting
parents or peers makes the person with AvPD hungry for relationships, but their longing
gradually develops into a defensive shell of self-protection against repeated criticisms.[4]

Treatment
Treatment of AvPD 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.[12] A key issue in treatment is
gaining and keeping the patient's trust, since people with AvPD will often start to avoid
treatment sessions if they distrust the therapist or fear rejection. The primary purpose of
both individual therapy and social skills group training is for individuals with AvPD to
begin challenging their exaggeratedly negative beliefs about themselves.[13]

Avoidant Personality Disorder has to date been a misunderstood and neglected entity—
either entirely ignored or confused with another disorder, such as Social Phobia. The
purpose of my revised Distancing is:
* To broaden our dynamic understanding of Avoidant Personality Disorder.
* To describe, understand and treat all avoidants, not just those who are shy and social
phobic.
* To develop a new therapeutic approach to avoidance, one I call “avoidance reduction.”
This is an eclectic method for treating avoidants composed of relevant techniques
borrowed from psychoanalytic, cognitive-behavioral, interpersonal, existential, and
supportive therapies.
Many clinicians fail to recognize Avoidant Personality Disorder, instead diagnosing
Social Phobia. Those who do Recognize Avoidant Personality Disorder emphasize
shyness and social phobia as its main features. However, these are not basic to all patients
with AvPD. What is basic to Avoidant Personality Disorder is not shyness or social
phobia but a severe and pervasive social and relationship anxiety, which is displayed in a
variety of ways. Therefore, there are not one but four subtypes of Avoidant Personality
Disorder, each of which requires a different psychotherapeutic approach.
Type I avoidants, the classic avoidants, are withdrawn. There are two subtypes of
withdrawn avoidants. A first is the shy individual who cannot seem to tolerate, flinches in
the face of, and pulls back from any form of social contact. The second suffers from a
Social Phobia, which is a delimited pull-back from a situation or event that symbolizes
relationships, for example, from public speaking or eating in public. Though shy and
social phobic Avoidants are the main and virtually exclusive focus of today’s scientific
literature, these avoidants may not even be in a majority, but may represent only the tip of
the avoidant iceberg.
Types II and III avoidants, almost entirely ignored by the literature, also suffer from
relationship anxiety but their relationship anxiety takes the form not of shyness or Social
Phobia but of unstable relationships due to a fear of commitment. Type II avoidants shift
from relationship to relationship afraid of closeness due to a fear of commitment
(“mingles” avoidants such as the perpetual bachelor or femme fatale). They are therefore
the opposite of withdrawn. These are hyperrelated individuals who can relate easily,
widely and well but have difficulty sustaining the relationships they form. Theirs are
unstable relationships, marked by a tendency to abandon relationships before they fully
develop, especially when closeness threatens and commitment looms.
Type III avoidants form lasting relationships only to disrupt them after months or years of
apparent functionality. These are what I call the “seven-year-itch” avoidants who form
what appear to be solid relationships only to tire of them after a shorter or longer period of
time then leave them with little warning. That is, they abandon their relationships after
some time has passed, and they often do so suddenly and without warning.
Type IV avoidants hide out in a codependent relationship with one person to avoid having
healthy relationships with many people. They sink into one relationship to avoid all
others. Some are dependent on their family. Others are dependent on a lover with whom
they form a merger relationship that protects them from the anxiety associated with
relationships outside of the primary relationship.
These are all patients with AvPD. Their dynamics are remarkably similar. They all require
avoidance reduction. However, the significant differences in the ways they manifest their
avoidance require a different therapeutic emphasis in each case. For example, while
exposure techniques may prove useful for Type I shy and social phobic avoidants, they
will likely be ineffective for Type II avoidants with a commitment phobia, who are more
likely to benefit from insight-oriented and cognitive therapy.
Effective treatment of Avoidant Personality Disorder requires a devoted approach
dedicated to reversing the underlying relationship anxiety via avoidance reduction. It will
be applicable to reduction of avoidance in all its forms.
Avoidance reduction should focus not only on fear of criticism (the official dynamic
explanation of avoidance) but also on the equally important fears of flooding, depletion,
and acceptance. Avoidants are not simply afraid of criticism and humiliation—the only
reason for avoidance currently identified in the official literature. They are also afraid of
being flooded by feelings they cannot tolerate, and of being depleted should they express
these feelings. Most importantly, they fear acceptance as much as they fear rejection
because they fear losing their identity and personal freedom.
In practice Avoidance reduction involves a pastiche of familiar psychotherapeutic
approaches in use today, including psychodynamic, cognitive-behavioral, interpersonal,
and supportive approaches, selected elements of which are combined for a synergistic
effect.
My book is for psychotherapists who will be better able to identify, understand and
manage Avoidant Personality Disorder from the detailed clinical descriptions, illustrative
clinical vignettes (including those from real life) and thorough exploration of the
psychodynamics, cognitive and interpersonal dynamics of the disorder included here.
It is also for victims of avoidants who can learn to better manage the people in their lives
who snub and otherwise neglect them.
It is also a self-help manual for avoidants themselves, individuals attempting to surmount
their relationship anxiety and form close, satisfying, meaningful relationships with others
without fear and regret.