Avoidant Personality Disorder


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Medical Description
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Crisis Intervention
"For a number of years there was little distinction between the avoidant
personality disorder and the schizoid or dependent personality disorders.
However with the modifications included in DSM-IV, the three are now 
sufficiently differentiated.
Essentially, avoidant patients long for close interpersonal relationships, but 
fear humiliation, rejection, and embarrassment, and so avoid and distance 
themselves from others. Schizoid patients have little need or desire for close 
interpersonal relationships, and so avoid and distance themselves from others. 
Dependent patients are clinging and submissive because of their excessive need 
for attachment.
Essentially then, avoidant patients withdraw because of fears of humiliation, 
embarrassment, and rejection.
This disorder has a relatively low prevalence in the general population 
(estimated to be between .5 and 1 per cent. In clinical settings, the disorder 
has been noted in 10 per cent of outpatients. The reason for this discrepancy 
is that the presence of a personality disorder increases the likelihood (to 
some degree) of suffering from other psychiatric problems (particularly with 
APD, depression and anxiety).
Avoidant Personality Disorder can be recognized by the following behavioral and 
interpersonal style, thinking or cognitive style, and emotional or affective 
Social withdrawal, shyness, distrustfulness, and aloofness characterize 
Avoidant patients behavioral style. Their behavior and speech are controlled, 
and they appear to be apprehensive and awkward. Interpersonally, they are 
sensitive to rejection. Even though they strongly desire closeness to others, 
they keep their distance and require unconditional approval before they are 
willing to "open up" to others. They tend to "test" others to see who can be 
trusted to like them.
The cognitive style of avoidants can be described as perceptually vigilant. 
This means that they scan the environment for clues to potential threats or 
acceptance. Their thoughts are often distracted by their hypersensitivity. They 
have low self-esteem because of their devaluation of their accomplishments and 
the overemphasis of their shortcomings.
Their affective or emotional style is marked by a shy and apprehensive quality. 
Because unconditional acceptance is relatively rare, they routinely experience 
sadness, loneliness, and tenseness. When more distressed, they will describe 
feelings of emptiness and depersonalization.
It should be noted that many more people have avoidant styles as opposed to 
having the personality disorder. The major difference has to do with how 
seriously an individual's functioning in everyday life is affected. The 
avoidant personality can be thought of as spanning a continuum from healthy to 
pathological. The avoidant style is at the healthy end, while the avoidant 
personality disorder lies at the unhealthy end.
*DSM-IV Criteria for Avoidant Personality Disorder (301.82)*
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 
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 settings, 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 might prove embarrassing.
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). 
American Psychiatric Association
The most common syndromes seen with APD include agoraphobia, social phobia 
(some clinicians see APD as possibly a generalized form of social phobia), 
generalized anxiety disorder, dysthymia (an emotion of depression), major 
depressive disorder (the syndrome with all the associated signs and symptoms), 
hypochondriasis, conversion disorder, dissociative disorder, and schizophrenia. 
It is now believed that avoidant personality disorder patients are excellent 
candidates for treatment (as opposed to some of the other personality 
disorders - this is probably due to the healthy desire and longing for close 
relationships). Various psychotherapeutic approaches can be successful, 
depending on the patients goals, preferences, and psychological mindedness, and 
the clinician's expertise.
Generally, the goal of therapy is to increase the patients self-esteem and 
confidence in relationship to others, and to desensitize the individual to the 
criticism of others. One must beware of the clinician that is overprotective of 
the patient and holds up progress - this sustains the poor view of self that 
the patient has come to treatment to remedy. The other clinician to beware is 
the one who forces the patient to face new situations prematurely, without 
proper preparation, and who then criticizes the patient for not being "brave" 
Until fairly recently, most publications spoke only of psychotherapeutic 
interventions, and only a few spoke of pharmacological treatments. Some of the 
problem is that many patients fear medications and their side effects just as 
they do any other new experience. Nevertheless, recent data indicates that some 
aspects of extreme social anxiety may be highly drug responsive. Since APD 
overlaps greatly with generalized social phobia (which is very responsive to 
MAOIs - a type of antidepressant). There are many documented cases of the 
successful treatment of APD with MAOIs (such as Parnate, Marplan, and Nardil). 
The use of Nardil (phenelzine) often shows improvement in specific fears and in 
confidence and assertiveness in social settings. The best medication 
intervention should be accompanied by psychotherapeutic methods appropriate to 
the individual patient. Medications alone will not give the kind of lasting 
improvement that combined treatment can provide. It is important to remember 
that medications are not always indicated in every case and that other 
considerations (such as general physical health, dietary restrictions, etc) 
matter in determining the need for, and possible efficacy, of medications. 
Psychotherapy alone works best with the higher functioning APDs, but combined 
treatment (psychotherapy and medications) seems to provide the best results for 
moderate and more severely disordered patients."



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