Avoidant Personality Disorder (AvPD)

1. Avoidant Personality Disorder(AvPD) Camelia Stefanescu, RNC, BSN CSUDH Dominguez Hills MSN-FNP

2. Definition • 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. American Psychiatric Association, 2000

3. Epidemiology • Prevalence is estimated to be 2.1–2.6% • Equally common in males and females • Not usually diagnosed in individuals younger than 18 years, although onset is in childhood or adolescence • Many report continued social anxiety throughout their lives Rettew, Jelinek & Doyle, 2004

4. Diagnostic Criteria – at least four must be present: • 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 American Psychiatric Association, 2000

5. Differential Diagnosis • Social Phobia, Generalized Type • Panic Disorder with Agoraphobia • Dependent Personality Disorder • Schizoid Personality Disorder • Schizotypal Personality Disorder • Paranoid Personality Disorder • Personality Change Due to a General Medical Condition • Symptoms that may develop in association with chronic substance use American Psychiatric Association, 2000

6. Comorbid disorders • Agoraphobia • Social Phobia • Generalized Anxiety Disorder • Dysthymia • Major Depressive Disorder • Hypochondriasis • Conversion Disorder • Dissociative Disorder • Schizophrenia American Psychiatric Association, 2000

7. Subtypes • Type I avoidants -This are the classical ones. -The shy individual who cannot seem to tolerate, and pulls back from any form of social contact, or -A delimited pull-back from a situation or event that symbolizes relationships, for example, from public speaking or eating in public. Kantor, 2003

8. Other subtypes • Type II avoidants- shift from relationship to relationship, afraid of closeness due to a fear of commitment (the perpetual bachelor or femme fatale) • Type III avoidants- form lasting relationships only to disrupt them after months or years of apparent functionality • Type IV avoidants- hide out in a codependent relationship with one person to avoid having healthy relationships with many people Kantor, 2003

9. Manifestations • Behavioral Appearance (Kantor, 2003) • Traits of shyness, timidity & withdrawing behavior • To protect themselves from being rejected, they reject others first • May put considerable time & effort into making themselves attractive to others • May consciously, or unconsciously, ensure that their appearance drives others away • They may dress ín the style of the era when the trauma occurred • May use frequent pauses & speak slowly • May also be over talkative • Insults or social faux pas can be used as a way to assure rejection

10. Manifestations • Interpersonal Conduct • Very reluctant to share their feelings or allow themselves to be vulnerable • Prone to “compulsive self-reliance” since they are most comfortable when depending solely on themselves • Cognitive Style • Excessively monitor the situation and are no longer paying sufficient attention to the interaction itself • Are also engaged ín external monitoring of the other person’s reactions Kantor, 2003

11. Manifestations • Affective expression • Little affect due to the fear that showing their emotions will make them vulnerable to rejection or humiliation • May appear tense & anxious • Self-perception • Low self-esteem • Very self-conscious • Frequently lonely (would like to be involved in relationships but cannot tolerate the feelings they get around other people) • Primary defense mechanism • Often escape into fantasy, read, watch TV, use a computer or daydream to escape from reality Kantor, 2003

12. Cause and Development • Biological factors, including heredity & prenatal maternal factors, set the foundation for personality & personality disorders (Kantor, 2003). • A timid temperament ín infancy may predispose individuals to developing AvPD later ín life (Sadock & Sadock, 2004) • An important environmental factor ín the development of avoidant personality disorder ís parental rejection (Kantor, 2003). • A 2nd environmental factor implicated ín the emergence of AvPD ís rejection by peer groups (Kantor, 2003).

13. Psychosocial Treatment • Psychotherapy appears to be the most beneficial form of treatment • Individual counseling is much preferred over group approaches as the condition poses obstacles to group interaction • Psychotherapeutic treatment must first be directed at solidifying an alliance with the therapist to prevent early termination of therapy • Assertiveness training might be useful Rettew, Jelinek & Doyle, 2004

14. Medication • It is recommended to medicate target symptoms rather than the personality disorder itself (Kantor, 2003). • Zoloft and other SSRI medications are considered first-line treatment for AvPD and social phobia. Benefits of SSRIs include relatively high tolerance, ease of administration, and relative safety in overdose (Rettew, Jelinek & Doyle, 2004). • Benzodiazepine: Clonazepam (Klonopin) - Used clinically to treat social anxiety in children and adolescents, although no controlled studies have been conducted in this population to document its efficacy (Rettew, Jelinek & Doyle, 2004).

15. References • American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders. Text Revision. (4th). Washington, DC:American Psychiatric Association. • Kantor, M. (2003). Distancing: Avoidant Personality Disorder. New York: Praeger Publishers. • Rettew, D. C., Jelinek, M. S., & Doyle, A. (2004). Personality Disorder: Avoidant Personality. Retrieved November 20, 2004, from eMedicine: http://www.emedicine.com/ped/topic189.htm • Sadock, B. J., & Sadock, V. A. (2004). Kaplan and Sadock's Comprehensive Textbook of Psychiatry. Boston, MA: Lippincott Williams & Wilkins