Avoidant Personality Disorder

 

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Aspect Avoidant Personality Disorder Generalized Social Anxiety Disorder
Key feature Hypersensitivity to negative evaluation by other people which results in social withdrawal and low self-esteem. A marked and persistent fear of most social or performance situations in which embarrassment may occur.
Diagnostic Criteria (DSM-IV) 
(possibly abridged)
A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
  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 they may prove embarrassing
  1. A marked and persistent fear of most social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing.
  2. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed Panic Attack.
  3. The person recognizes that the fear is excessive or unreasonable.
  4. The feared social or performance situations are avoided or else are endured with intense anxiety or distress.
  5. The avoidance, anxious anticipation, or distress in the feared social or performance situation(2) interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
  6. In individuals under age 18 years, the duration is at least 6 months.
  7. The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder.
  8. If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it.
Diagnostic Criteria (ICD-10)
(possibly abridged)
Personality disorder characterized by at least 3 of the following:
  1. persistent and pervasive feelings of tension and apprehension;
  2. belief that one is socially inept, personally unappealing, or inferior to others;
  3. excessive preoccupation with being criticized or rejected in social situations;
  4. unwillingness to become involved with people unless certain of being liked;
  5. restrictions in lifestyle because of need to have physical security;
  6. avoidance of social or occupational activities that involve significant interpersonal contact because of fear of criticism, disapproval, or rejection.
Associated features may include hypersensitivity to rejection and criticism.
All of the following criteria should be fulfilled for a definite diagnosis:
  1. the psychological, behavioral, or autonomic symptoms must be primarily manifestations of anxiety and not secondary to other symptoms such as delusions or obsessional thoughts;
  2. the anxiety must be restricted to or predominate in particular social situations; and
  3. avoidance of the phobic situations must be a prominent feature.
Comorbidity Dysthymic Disorder, major depression, anxiety disorders.

Individuals with AvPD may have comorbidity with some other personality disorder such as DPD (Dependant Personality Disorder), BPD (Borderline Personality Disorder), and more severe schizophrenic disorders.
80% of patients with any type of SAD meet diagnostic criteria for a comorbid condition.

The most common comorbid conditions include major depression, PTSD, panic disorder, substance abuse disorder and schizophrenia.
Prevalence 0.5%-1.0% For all types of SAD: Lifetime Prevalence (occurs at least once in a lifetime): 13.3% Annual Prevalence rate: 7.9%.

The Anxiety Disorders Association of America (ADAA) (2002) reported that SAD of all types affects 3.7% of the population .
Age of onset Onset is in adolescence or early adulthood.

Cannot be diagnosed until adulthood (age 18).
For all types of SAD: Onset typically occurs between 11 and 19 years of age. Onset after age 25 is rare.

Mean age of onset is between ages 14 and 16.
Sex distribution Found equally in both males and females. Slightly more females than males have any type of SAD.
Etiology Weak evidence of major biogenic influences; full development of AvPD is likely due to significant environmental influences, including parental rejection or peer rejection. Predisposing factors include biochemistry (physiological imbalance in neurotransmitters), genetics, childhood upbringing (overly cautious, overly critical or assertiveness-suppressing parents) and cumulative stress
Personality traits Avoidant Personality Disorder Generalized Social Anxiety Disorder
Extroversion Significantly higher levels of low extroversion (introversion) than in SAD.  
Self-Esteem View themselves as defective, unable to fit in with others, being unlikable, and being inadequate. Individuals with AvPD usually refer to themselves with contempt. Low self-esteem may begin in early childhood and often fuels social anxiety and avoidance. High self-esteem does not contradict the existence of SAD.
View of Others Individuals with AvPD view the world as unfriendly, cold, and potentially humiliating; they come to expect that attention from other people will be degrading or rejecting.  
Sensitivity Slightly higher levels of interpersonal sensitivity and mistrust in AvPD than in SAD.  
Reaction to criticism Individuals with AvPD tend to respond to low-level criticism with intense hurt.  
Neuroticism Significantly higher levels of neuroticism in AvPD than in SAD, with or without other comorbid personality disorders.  
Functioning Avoidant Personality Disorder Generalized Social Anxiety Disorder
Social Severe social inhibition and feeling of social inadequacy and inferiority.

Greater disability on all levels than in SAD.
 
Intimate Relationships Appear self-involved and uncaring, but long for affection and fantasize about idealized relationships .

Restraint in intimate relationships; few or no close friends, but intimacy is possible with people who are experienced as safe.
Roughly the same level of impairment in AvPD as in SAD, given the absence of other comorbid personality disorders.
Occupational More impaired in AvPD than in SAD; greater disability on all levels.  
Physical Symptoms   Blushing, heart palpitations, shortness of breath, sweating and trembling.

Slightly more somatic complaints in patients with SAD than with AvPD.
Treatment Avoidant Personality Disorder Generalized Social Anxiety Disorder
Medications Unlike many other personality disorders, AvPD responds to antidepressants.

MAOIs (Nardil, Parnate), SSRIs, SNRIs, benzodiazepines (Klonopin, Xanax, for non-drug-addicts).
SSRIs (Paxil, Celexa, Lexapro, Zoloft, Luvox) are considered drugs of first choice although MAOIs (Nardil) and benzodiazepines (Klonopin, Xanax) are often more effective.

Beta-blockers are not known to be effective for generalized SAD.
Therapy CBT, CBGT.

Behavioral therapy consisting of graduated exposure, social skills training, and systematic de-sensitization.

Cognitive therapy consisting of alteration of patterns of negative self-talk.
CBT, CBGT.

The presence of Avoidant Personality Disorder in SAD does not influence long-term outcome of behavioral therapy.


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