Distancing: Revised and Expanded 2003

The author Dr Martin Kantor has generously agreed to write a summary of his revised and expanded book for use on this website, and that summary is reproduced below.

Preface
DESCRIPTION
Why Has Avoidant Personality Disorder Received So Little Attention?
The Literature
The Mental Status Profile
Types of Avoidants
Healthy Avoidance
Avoidant People
Sociocultural Manifestations
Course
Comorbid Disorders: Comorbidity with Schizotypal, Schizoid and Affective Disorder
Comorbid Disorders: Comorbidity with "Neurotic" Spectrum Disorders
Comorbid Disorders: Comorbidity with Other Personality Disorders

CAUSE: An Overview

THERAPY
An Overview of Avoidance Reduction
Psychodynamically Oriented Psychotherapy
Cognitive Behavioral Therapy
Interpersonal Therapy
Supportive Therapy
Pharmacotherapy
Therapeutic Modifications for Treating Avoidants
Treating Depressed Avoidants

About the Author
MARTIN KANTOR is a psychiatrist on the staff of the Department of Veterans Affairs Medical Center, East Orange, New Jersey. He is the author of The Human Dimension of Depression (Praeger, 1992), Diagnosis and Treatment of the Personality Disorders (1992), Problems and Solutions: A Guide to Psychotherapy for the Beginning Psychotherapist (Praeger, 1990), and Determining Mental Status: The "Physical Examination" of Psychiatry (1988).

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.