Avoidant Personality Disorder

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Avoidant personalities are seemingly shy, lonely, hypersensitive individuals with low self-esteem. Although they are desperate for interpersonal involvement, they avoid personal contact with others because of their heightened fear of social disapproval and rejection sensitivity.

Clinical Presentation

The Avoidant Personality Disorder is characterized by the following behavioral and interpersonal styles, thinking or cognitive styles, and emotional or affective styles.

The behavioral style of avoidant personalities is characterized by social withdrawal, shyness, distrustfulness, and aloofness. Their behavior and speech is both controlled and inactive, and they appear apprehensive and awkward.

Interpersonally, they are rejection-sensitive. Even though they desire acceptance by others, they keep distance from others and require unconditional approval before being willing to “open up.” They gradually “test” others to determine who can be trusted to like them.

DSM-5 Characterization

Individuals with this avoidant personality disorder are characterized by an unremitting pattern of being socially inhibited, feeling inadequate, and overly sensitive to the negative evaluations of others. This is because they view themselves as socially inept, unappealing, or inferior to others.

Sufferers of this disorder consistently avoid work activities that require close interpersonal contact, for fear of being criticized or rejected. They will not get involved with others unless they are certain of being accepted.

Fearing they will be shamed or ridiculed, they act with restraint in intimate relationships.

In anticipation of shame or ridicule, they are uncomfortable and are hesitant in intimate relationships. Similarly, they experience feelings of inadequacy and inhibition in new interpersonal situations. Not surprisingly, they refuse to take personal risks or engage in activities that may prove embarrassing (American Psychiatirc Association, 2013).

Biopsychosocial – Adlerian Conceptualization

The following biopsychosocial formulation may be helpful in understanding how the Avoidant Personality pattern is likely to have developed.

Biologically, these individuals commonly were hyperirritable and fearful as infants, and they most likely exhibited the “slow to warm” temperament (Thomas & Chess, 1977).

Individuals with this personality pattern are also likely to have experienced various maturational irregularities as children. Their irregularities and their hyperirritable pattern are attributed to low arousal of their autonomic nervous systemOpens in new window (Millon & Everly, 1985).

Psychologically, those with avoidant personalities typically view themselves as “See, I am inadequate and frightened of rejection.” They are likely to view the world as some variant of the theme: “Life is unfair—people reject and criticize me—but, I still want someone to like me.” As such, they are likely to conclude: “Therefore, be vigilant, demand reassurance, and if all else fails, fantasize and daydream about the way life could be.”

A common defense mechanismOpens in new window of the avoidant personality is fantasy. Thus, it is not surprising that avoidant personalities are major consumers of romance novels and soap operas.

Socially, predictable patterns of parenting and environmental factors can be noted for the avoidant personalty disorder. The avoidant personality is likely to have experienced parental rejection and/or ridicule. Later, siblings and peers will likely continue this pattern of rejection and ridicule.

The parental injunction is likely to have been: “We don’t accept you, and probably no one else will either.” They may have had parents with high standards and worried that they may not have met or would not meet these standards, and therefore would not be accepted.

This avoidant pattern is confirmed, reinforced and perpetuated by the following individual and systems factors:

A sense of personal inadequacy and a fear of rejection leads to hypervigilance, which leads to restricted social experiences.

These experiences, plus catastrophic thinking, lead to increased hypervigilance and hypersensitivity, leading to self-pity, anxiety and depression, which leads to further confirmation of avoidant beliefs and styles.

Treatment Considerations

In terms of treatment goals and strategies, there is little reported research on treating the avoidant personality. However, the goal of therapy is to increase the individual’s self-esteem and confidence in relationship to others and to desensitize the individual to the criticism of others.

Desensitization techniques appear to be much more useful and expedient in this regard. Assertiveness training and shyness training are reportedly very affective with the Avoidant Personality pattern (Turkat & Maisto, 1985). As with other personality disorders, medication can be useful for symptoms such as depression and anxiety associated with the avoidant pattern.

Case Example: Ms. A.
Ms. A. is a 35-year-old, African-American female who works as an administrative assistant. She is single, lives alone, and was referred by her company’s human resources director for evaluation and treatment following three weeks of depression and social isolation. Her absence from work prompted the referral. Ms. A.’s symptoms began soon after her supervisor told her that she was being considered for a promotion. Ms. A. reports having difficulty relating to her peers, both in early life, as well as currently.

Family constellation
She is the older of two siblings, with a brother who is eight year younger than her. For all practical purposes, she was psychologically an only child. Ms. A. reports that she was her father’s favorite until her brother was born. As a child, she had difficulty relating to her peers while in school and was often criticized. Typically, she responded by isolating and avoiding others. She mentioned that her parents were and continue to be unsupportive, demanding, and critical toward her. Three family values worth noting are “children are to be seen and not heard,” “your worth depends on what you achieve in life,” and “family secrets do not leave the family.”

Early recollections
Her earliest recollection involves feeling displaced and no longer wanted by her parents the day her mother brought her newborn brother home. Her father said it was the happiest day of his life, and Ms. A.’s reaction was to run out of the house and hide in her tree fort feeling angry, alone, sad, and rejected, and thinking that nobody wanted her anymore. Another recollection involved being told that what she drawn in art class was awful. Her response was to feel sad and hurt and conclude that something must be wrong with her if she couldn’t draw.

Adlerian case conceptualization
Ms. A.’s increase social isolation and depressive symptoms seem to be her discouraged reaction to the news of an impending job transfer and promotion, given her history of having critical and demanding people in her life. She avoids most relationships and has a history of isolating throughout her childhood.

Ms. A.’s presenting problems are understandable when viewed from the perspective of her life style. Her style of relating with others mirrors the tentative and avoidant manner in which she related to family members. She sought a safe way to connect to family members without being criticized or having unreasonable demands put on her. She views herself as inadequate and defective as a person, and views life and others as demanding, harsh, arbitrary, and critical. Therefore, Ms. A. found her place by avoiding most relationships, socially isolating, and overly investing in those she deems as trustworthy. This allowed her to avoid being criticized and helped her “feel safe.” Her strategy of avoiding relationships and withdrawing whenever she feels unsafe works. However, the price she pays to feel “safe” is high: she is lonely, has limited relational skills and experiences, and desires a close intimate relationship that seems unlikely.

Treatment plan and implementation
Decreasing discouragement and depressive symptoms, increasing social interest and social relating, and enhancing relational skills are the primary goals of treatment. Interpretation will be utilized to process Ms. A.’s life-style convictions and basic mistakes. The focus will be on modifying her faulty convictions of avoidance to feel safe. Because of her discomfort in talking with a neighbor, she will be encouraged to act “as if” she were comfortable. A referral will be made for a medication evaluation and, if indicated, medication monitoring will be arranged.
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