Avoidant Personality Disorder

Personality Disorders
A personality disorder is a severe disturbance in the characterological constitution and behavioural tendencies of the individual, usually involving several areas of the personality, and nearly always associated with considerable personal and social disruption. Personality disorder tends to appear in late childhood or adolescence and continues to be manifest into adulthood.

Avoidant Personality Disorder (extracts from http://www.open-mind.org/)
Avoidant personality disorder (APD) ís considered to be an active-detached personality pattern, meaning that avoidants purposefully avoid people due to fears of humiliation & rejection. It ís thought to be a pathological syndromal extension of the “normal inhibited” personality, which ís characterized by a watchful behavioral appearance, shy interpersonal conduct, a preoccupied cognitive style, uneasy affective expression & a lonely self-perception (Millon & Everly). According to this view, the avoidant pattern seems to range ín varying degrees along a symptomological continuum from mild to extreme. In mild cases, a person may be said to be normally shy, whereas extreme cases indicate personality disorder.

ICD-10 Criteria (Europe)
The ICD-10 Classification of Mental and Behavioural Disorders World Health Organization, Geneva, 1992 , describes F60.6 Anxious (Avoidant) Personality Disorder as:
A personality disorder characterized by at least 3 of the following:

DSM Criteria (United states)
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), describes APD as:
A pervasive pattern of social inhibition, feelings of inadequacy & hypersensitivity to negative evaluation, beginning by early adulthood & present ín a variety of contexts, as indicated by 4 (or more) of the following:

How does APD manífest ítself?
The usual onset for APD ís early adulthood, with an equal prevalence rate among women & men (APA). According to one study however, (Greenberg & Stravynski, 1985) most of the people being referred for professional help for social dysfunction, considered to be the same disorder as APD by Marks (1987), were single men. One suggested hypothesis for this finding ís that society expects men to be the initiators ín romantic relationships. Therefore, when they do not form relationships, ít ís seen as more of a problem than women who do not initiate relationships but are not expected to ín any case (Marks). Millon & Everly have suggested 6 dimensions onto which the symptoms of APD can be mapped.

1.	Behavioral Appearance Avoidants do exhibit the stereotypical traits of shyness, timidity & withdrawing behavior. To those who know them well, the avoidants’ mistrust of others may also be apparent as an almost constant wariness. However, Kantor (1993) argues that behavioral hostility ís also typical of those suffering with APD. Avoidants may use their shyness as a way to hurt others by preventing them from becoming close. Alternatively, they will demonstrate their hostility ín a more overt manner by insulting people who attempt to be friendly, for example. This reaction may be because they are identifying their aggressor & “deal with feared rejection by becoming rejecting themselves.” These expressions of hostility could be seen as defensive fight responses. To protect themselves from being rejected, they reject others first. This ís maladaptive because the avoidants will tend to reject many people who would never have rejected them ín the first place. In terms of appearance, íf ít ís affected at all by APD, ít will tend to be affected ín one of 3 ways. 1st, avoidants may put considerable time & effort into making themselves attractive to others. The idea behind this ís, at least they will be liked for their looks, íf not for themselves. 2nd, they may consciously, or unconsciously, ensure that their appearance drives others away. This provides them with some control over their lives. Rather than waiting helplessly to be rejected, they ensure rejection from the start by their own actions. 3rd, ín the case of avoidants who are suffering from PTSD, for example, they may dress ín the style of the era when the trauma occurred. This form of dress ís an indication that they are living ín the past. Speech ís may also be affected ín APD. Avoidants may be quite silent. As Jerome Kagan explains, “For a rabbit, freezing on a lawn ís a sign of fear. I believe that speechlessness ís a similar diagnostic sign for us… There’s a circuit ín the brain that controls our vocal cords & becoming quiet can be one sign of fear.” (Galvin, 1992). When they do speak, avoidants may use frequent pauses & speak slowly (Millon & Everly). This ís contrary to what we read regarding social phobia, where pauses ín speech tended to be avoided because they were thought to be a sign of lack of knowledge. Avoidants may also be overtalkative, possibly due to an adrenic discharge or a false belief, such as continuously talking will prevent death. For avoidants who try to put people off with their behavior, insults or social faux pas are commonly used as a way to assure rejection (Kantor). While this does essentially realize their worst fear, ít does again give avoidants some control over how others react to them.
2.	Interpersonal Conduct Avoidants often test others to determine whether or not they are being sincere ín their friendliness. Because they may frequently see rejection where ít does not exist, people will tend to fail these tests & then later be avoided because they may reject or humiliate those with APD (Millon & Everly). They will, therefore, frequently have difficulty beginning & maintaining relationships (Kantor), partly because they have difficulty trusting others & thus, are very reluctant to share their feelings or allow themselves to be vulnerable. As a protective measure against the humiliation & rejection, they may become avoidant of others. On the other hand, avoidants may form relationships, even making an effort to meet new people. However, these people are kept at a distance. Therefore, this group of avoidants ís avoiding intimacy, rather than avoiding people altogether.
3.	Cognitive Style Avoidants excessively monitor the situation to the extent that they are trying to process so much information, they are no longer paying sufficient attention to the interaction itself (Millon & Everly). The literature on social phobia suggests that the phobics are unable to follow the interaction because they are so focussed on their internal reactions. However, the research on avoidant personality disorder also emphasizes that the avoidants are engaged ín external monitoring of the other person’s reactions as well. This additional processing of information could contribute to the increased severity of APD over social phobia. The excessive monitoring by avoidants, combined with a hypersensitivity to rejection makes their perception of rejection almost inevitable. Their dysfunctional thought processes may also include fear of being vulnerable, because ít makes ít easier to get hurt or humiliated. They may also be perfectionists & reject anyone who does not live up to their impossible standards. This may again be a case of rejecting someone before they are rejected themselves. Another possibility ís that they are degrading the other person so that íf they are rejected they will find ít less painful because they didn’t like the person anyway. Some people believe that relationships are just too much work & aren’t worth the effort. Rationalization may also be present ín this belief with the idea that ít ís not because they are unable to form relationships that they don’t have any, ít ís that they do not want to waste their time on relationships. Some avoidants even believe that they must avoid intimacy because “giving love to others reduces the energy they have available for themselves & that they need for their vital life processes,” (Kantor).
4.	Affective Expression People with APD may exhibit little affect due to the fear that showing their emotions will make them vulnerable to rejection or humiliation (Kantor; Millon & Everly). To observers, avoidants may appear tense & anxious (Millon & Everly).
5.	Self-perception Avoidants tend to have low self-esteem & believe that they are unworthy of being ín successful relationships. They are also very self-conscious, frequently lonely & see their accomplishments as being of little or no worth (Millon & Everly).
6.	Primary Defense Mechanism To cope with their unhappiness, people with APD often escape into fantasy which ís “a ‘safe’ medium ín which to discharge affection, aggression or other impulses that would otherwise be inappropriate, uncomfortable or impossible to achieve ín reality,” (Millon & Everly). Avoidants will tend to read, watch TV or daydream to escape from reality.

Cause & Development
From an evolutionary point of view, the “fight-or-flight” dichotomy suggests that both hostility & avoidance are naturally occurring responses to fear. Both are thought to be based on anxiety evoked by the presence of a feared stimulus object or situation. However, avoidance can co-vary with fear, vary inversely or vary independently (Rachman & Hodgson, 1974). Therefore, avoidance behavior seems to be more complex than ís accountable for by the simple presence of fear or anxiety. What appear to be purposeful hostile reactions to others, for example, may be indicative of highly complex psychological processes.
It ís commonly believed that biological factors, including heredity & prenatal maternal factors, set the foundation for personality & personality disorders, while environmental factors shape the form of their expression (Millon & Everly). In the case of avoidant personality disorder, the evidence of major biogenic influences ín íts etiology & development ís speculative & weak (Millon & Everly). However, there ís some evidence that a timid temperament ín infancy may predispose individuals to developing APD later ín life (Kaplan & Sadock, 1991). While shyness appears to indicate underactivity, Kagan believes that this inherited tendency to be shy ís actually the result of overstimulation or an excess of incoming information. Timid individuals cannot cope with the excess of information & so withdraw from the situation as a self-protective measure. The inability to cope with this information overload may be due to a low autonomic arousal threshold (Venebles, 1968). The same mechanism may also be responsible for the avoidant’s hypervigilence. However, ít ís generally believed that these biological substrates exist within the avoidant personality as a biological foundation for the emergence of the disorder itself & that full development of APD ís likely due to significant environmental influences (Millon & Everly).

Parental Rejection
An important environmental factor ín the development of avoidant personality disorder ís parental rejection (Kantor; Millon & Everly). Although normal, healthy infants may encounter varying degrees of parental rejection, the amount of rejection seems to be particularly intense &/or frequent for people who subsequently develop APD. Frequent or intense rejections crush children’s natural energy & optimism, leaving instead attitudes of self-deprecation & feelings of social isolation. Rejection by parents appears to be particularly devastating because ít may be interpreted as a direct contradiction to the commonly held edict of unconditional love & acceptance of offspring by their parents. The rejected child asks, “if my parents won’t accept me, who will?”, yet some children learn that their parents do not accept them, thus the question ís always present & every person the avoidant interacts with will be put to the test.

Although avoidance ín children does not appear to be necessarily linked to APD ín adulthood, ít appears that particular kinds of rejection by parents can alter the attitude & behavior of children ín a way that disposes them to develop the disorder more easily later ín life. For example, Kantor suggests that íf a child’s expression of positive emotion ís met with remoteness, criticism or punishment, he might learn to spare himself anguish by keeping positive feelings to himself. Perhaps such a child might abandon positive feelings altogether. There ís little doubt that this would jeopardize later adult relationships.

Likewise, íf a child’s negative feelings are rejected, for example, íf she ís repeatedly told “it’s bad to feel angry”, she might forego otherwise workable relationships ín order to avoid not only the intermittent feelings of dissatisfaction or anger that are an inevitable part of practically all close relationships, but also her ambivalence toward negative feelings ín general.

Furthermore, parental rejection may indicate some underlying parental fear, which the child unconsciously imitates. In such a case, the child may learn not only to fear rejection from others, but also to believe that the world ís a fearful place.

Peer Rejection
A 2nd environmental factor implicated ín the emergence of APD ís rejection by peer groups. If a child leaves a hostile or rejecting situation & encounters positive reinforcing experiences outside of the home, early rejection by parents need not result ín self-deprecating attitudes. However, íf parental or familial (including siblings) rejection ís compounded by rejection from a peer group, the prognosis points heavily toward a personality disorder.

Repeated social interactions expose an individual to potential rejection over a sustained period of time. Such rejection, íf ít occurs, can wear down the individual’s sense of self-competence & self-esteem. Following humiliation & rejection by peers, individuals then begin to criticize themselves. Feelings of loneliness & isolation are made worse because of harsh self-judgments & increasing feelings of personal inferiority & self-worthlessness contribute to withdrawing behavior. Rejection by their peers seems to validate the rejection by their parents. When children cannot turn to their parents, their peers, or even themselves for gratification or validation, they retreat. Avoidant personality may be the result.

Other Factors
In addition to rejection by parents & peers, ít ís speculated that several other factors can play more & less significant roles ín the development & persistence of APD. For example, children who are infantalized by their parents may have difficulty relating to people outside of the family. As adults they may be regressive & dependent ín relationships. Avoidance may also be recommended by parents, peers, teachers, entertainers, religious leaders & the media as protection against the evils of the world. Unresolved rivalry with siblings has been suspected of inducing transferential jealous competition among individuals, leading to avoidant behavior. Also, sexual feelings, for example Freud’s (1950) “incest taboo”, may unconsciously lead to avoidance of close relationships with parents & later with potential partners. It has been noted that sometimes avoidants isolate themselves ín order to manage strong ambivalent or negative feelings toward sex (Kantor). In psychopathic proportions, avoidance may lead to a purposive distancing ín order to enhance sexual fantasies (Shapiro, 1981). In some cases, a more poignant expression of sexual disgust may be expressed as love revulsion, a condition ín which the avoidant has learned to “love” isolation, not because ít ís a real preference but because ít ís a defense against a forbidden desire to be with others (Kantor). Finally, transference can lead to avoidant behavior when an individual distances herself from people who remind her of something or someone she disliked or feared ín the past — often parents, but also others outside of the family.

The Self-perpetuatíng Cycle of APD
Avoidants have limited contact with others when they use avoidance to protect themselves from being rejected. People notice the withdrawing behavior of the avoidant individual which leads either to a reciprocal avoidance by the observer or ridicule of the avoidant by those observing his hermit-like behavior. As Millon & Everly point out, often people who appear weak or timid attract the attention of those who enjoy belittling others. A cycle of withdrawal, ridicule or rejection, further withdrawal & so on, perpetuates the avoidant personality disorder.

The avoidant ís painfully alert to the minutest signals of rejection from others. Unfortunately, being hypersensitive to rejection often lowers avoidants’ ability to correctly perceive what ís & what ís not rejection. They may imagine rejection where none exists or view a minor & partial rejection as one that ís major & complete. They feel that every rejection follows from a thoughtful evaluation of their real worth when they know that people who reject others sometimes do so because they have problems of their own (act reflexively & transferentially rather than thoughtfully & realistically) (Kantor). The strategy they have adopted to protect themselves backfires & the fears associated with the negative view of themselves seems to be confirmed. As the pattern repeats itself & the problem magnifies, the avoidant finds him or herself ín a world of self-fulfilling prophecy.

Furthermore, as avoidants withdraw more & more from social situations, they are left with an increasing amount of time to reflect upon their sorrowful state. Like an unrequited love affair, avoidants’ desire for interpersonal relationships peaks & most often the conclusion they reach ís that they are not only incapable of improving their attractiveness or likeability to others, but that they do not even deserve acceptance. This fosters more avoidance & alienation (Millon & Everly).

Finally, we cannot overlook the importance of operant conditioning ín the perpetuation of avoidant personality disorder. The avoidant desires social affiliation yet ís fearful of rejection & humiliation. The pattern of avoidant, seclusive, aloof & hypersensitive behavior that characterizes the disorder ís negatively reinforcing to the individual. That ís, through avoidant behaviors, these individuals can reduce the probability that they will be rejected or humiliated. Thus the behavior ís reinforced & the disorder ís made more severe (Millon & Everly).

Treatment
Avoidance reduction ís typically an action-oriented approach to handling the causes, complications & consequences of APD. It borrows from the active techniques found ín other psychotherapies. For example, “total push”, from behavior therapy, forces avoidants to face social interactions for longer periods of time; supportive therapy gives encouragement (“you can do it”), positive feedback (“you are good enough to succeed”) & reassurance (“you can handle the anxiety”); family therapy tries to convince the smothering family to stop infantilizing the individual; & pharmacological therapy advises administering anti-depressant medication to help allleviate the avoidant’s anxiety. Generally, avoidants are encouraged to “do” rather than contemplate, to engage themselves ín fearful situations as a means of overcoming their fear.

In summary, those with APD are extremely sensitive toward & fearful of, rejection by others. Their reaction to this fear may be a flight response, ín the case of avoidance, but may also be a fight response, ín the case of hostility. While genetics may predispose individuals to developing this disorder, ít ís thought that the environment or more specifically, early failed relationships are the pivotal cause of the development of APD. Through their own dysfunctional thoughts & behaviors, avoidants inadvertently perpetuate their suffering. Active behavioral therapies are recommended & sometimes medication ís administered.

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

1.	avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval or rejection
2.	ís 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.	ís preoccupied with being criticized or rejected ín social situations
5.	ís inhibited ín new interpersonal situations because of feelings of inadequacy
6.	views self as socially inept, personally unappealing or inferior to others
7.	ís unusually reluctant to take personal risks or to engage ín any new activities because they may prove embarrassing