Which of the following is a characteristic of the avoidant personality disorder?

Avoidant/Restrictive Food Intake Disorder

Previously encompassing “feeding disorder of infancy or early childhood” in the DSM-IV,11 ARFID was introduced into the nomenclature in the DSM-5 and its former criteria adjusted to include a wider variety of presentations.83 ARFID is a diagnosis that can occur across the life span. The signature feature of ARFID is a disturbance in eating or feeding that yields significant nutritional or psychosocial compromise and/or requires special feeding measures (e.g., dietary supplements to correct a nutritional deficiency or enteral feeding to supply calories). The food intake disturbance often results from sensory-based avoidance, feared consequences of eating associated with aversive experiences, or lack of interest in eating. The disturbance cannot be ascribed to AN or a medical condition unless the nutritional deficit for the latter is more severe than would normally be expected and requires additional clinical measures. ARFID can be comorbid with neurodevelopmental disorders, such as intellectual disability and autism spectrum disorder; for the latter comorbidities, ARFID is more common among males compared with those who have AN or BN. The nutritional deficits associated with ARFID may have an adverse impact on growth, development, and learning.1, 84 It is important to note that the diagnosis of ARFID covers a range of different clinical presentations. To diagnose ARFID, the clinician must elicit a comprehensive history to determine food intake with respect to range and amount, and also to establish whether the nutritional deficits are associated with weight loss, failure to gain weight as expected, or faltering growth; clinical or laboratory abnormalities; dependency on nutritional supplements or tube feeding; or interference with the individual’s social and emotional functioning.84

Abstract

Avoidant personality disorder (APD) is characterized by severe and chronic social anxiety. Prospective studies demonstrate modest symptomatic stability and chronic functional impairment. Current diagnostic conceptualizations distinguish APD from other distress disorders, such as anxiety and depression, by a long-standing pattern of social avoidance accompanied by fears of criticism and low self-worth so pervasive that it defines who a person is. New proposals to refine the diagnosis include the addition of trait components focusing on negative emotionality, introversion, anhedonia, and compulsive risk aversion to better distinguish APD from other anxiety-related disorders. APD is a useful diagnostic construct that captures an entrenched manifestation of social anxiety driven by feelings of low self-worth and the expectation of rejection.

Conclusions

APD is an internally consistent personality disorder that can be reliably measured. As with many other personality disorders it has both state and trait personality components. APD causes morbidity through interfering with social interactions and may affect such important life parameters as dating, marriage, friendship and employment. APD is also relatively common in general and clinical populations. This prevalence and morbidity make it an appropriate focus of clinical treatment. APD and SAD share symptoms (differing only in severity), are responsive to the same pharmacological and psychotherapeutic interventions and seem to be identical genetically. The best conceptualization is that SAD is a milder variant of APD and that they are the same disease. APD’s potential response to treatment engenders cautious clinical optimism about its treatment.

Avoidant Personality Disorder

Avoidant personality disorder (AVPD) was a new addition to DSM-III (APA, 1980). A criticism of its inclusion was that it had little prior recognition within the PD literature. However, it is now one of the more frequently diagnosed PDs, as timid, anxious, and insecure introversion is a common social and clinical problem (Sanislow et al., 2012; Millon, 2011).

AVPD is a pervasive pattern of timidity, inhibition, inadequacy, and social hypersensitivity (APA, 2013). Persons with AVPD will have a strong desire to develop close, personal relationships but will also feel too insecure and uncertain to approach others or to express their feelings. Its diagnostic criteria include an inhibition within interpersonal situations because of feelings of inadequacy, preoccupation with fears of being criticized or rejected, an unwillingness to get involved with others unless certain of being accepted, and fears of being shamed and ridiculed (APA, 2013).

The most difficult differential diagnosis for AVPD is with social anxiety disorder (Sanislow et al., 2012). Both involve an avoidance of social situations, social anxiety, and timidity, and both are said to emerge from a childhood of shyness and introversion (APA, 2013). There is perhaps no meaningful distinction between them. There is an ongoing debate over whether this condition is best conceptualized as an anxiety or a PD. In any case, it is readily understood as a combination of the fundamental personality traits of introversion and neuroticism (APA, 2013; Sanislow et al., 2012).

Many persons with AVPD may also meet the criteria for DPD (Trull et al., 2012). This might at first glance seem unusual, given that AVPD involves social withdrawal, whereas DPD involves social clinging. However, once persons with AVPD are able to obtain a relationship, they will often cling to this relationship in a dependent manner. A distinction between these disorders is best made when the person is seeking a relationship. Avoidant persons tend to be very shy, inhibited, and timid (and are, therefore, slow to get involved with someone), whereas dependent persons urgently seek another relationship as soon as one ends.

Timidity, shyness, and social insecurity are not uncommon problems within the general population and AVPD is one of the more prevalent PDs within clinical settings (Torgersen, 2012). It appears to occur equally among males and females. Persons with AVPD often were shy, timid, and anxious children. Adolescence may have been a particularly difficult developmental period, due to the importance of social status and dating.

AVPD may involve elevated peripheral sympathetic activity and adrenocortical responsiveness, resulting in excessive autonomic arousal, fearfulness, and inhibition (Roussos and Siever, 2012). The pathology of AVPD, however, may be as much psychological as neurochemical, with the timidity, shyness, and insecurity being a natural result of a cumulative history of denigrating, embarrassing, and devaluing experiences (Millon, 2011; Sanislow et al., 2012). Underlying AVPD may be excessive self-consciousness, feelings of inadequacy or inferiority, and irrational cognitive schemas that perpetuate introverted, avoidant behavior.

Persons with AVPD will seek treatment for their avoidant personality traits, although many will initially seek treatment for symptoms of anxiety, particularly social anxiety disorder. It is perhaps important in such cases, though to consider that the shyness might not be due simply to a neurochemical dysregulation or dyscontrol of anxiousness (Sanislow et al., 2012). There may instead be a more pervasive psychopathology, involving beliefs of interpersonal insecurity and inadequacy (Millon, 2011). Hence it may be important to address underlying fears and insecurities regarding attractiveness, desirability, rejection, or intimacy.

Avoidant Personality Disorder (Box 12-9)

Cluster C

Avoidant personality disorder is characterised by inhibition in social situations, feelings of inadequacy, and sensitivity to negative evaluation by others. Such individuals tend to be shy and lonely, but unlike schizoid individuals they would rather be able to interact with others. They may become isolated and avoid activities and occupations that involve interactions, as they fear rejection. Differentiating avoidant personality disorder from social phobia is difficult, and it has been suggested that these two diagnoses represent the same underlying condition. Frequently coexisting personality disorders include borderline, schizotypal, schizoid and paranoid.

Dependent personality disorder is characterised by the need to be cared for, fear of abandonment, and submissive and clingy behaviour in relationships. Such individuals usually have negative views of themselves and subordinate their own needs in a relationship with a domineering partner. Frequently coexisting personality disorders include borderline, avoidant and histrionic.

Obsessive–compulsive personality disorder is characterised by rigidity, a need for control, perfectionism and orderliness. Such individuals find difficulty completing tasks efficiently because of their perfectionism, and may become frustrated, angry or despondent when their need to be in control or to be perfect is not realised. Differentiation from obsessive–compulsive disorder should be easy, as obsessions and compulsions are not actually a feature of the personality disorder. Unlike other categories, coexistence with other personality disorders is uncommon.

Avoidant Personality Disorder

The avoidant personality is easily hurt by criticism and devastated by the slightest hint of disapproval. Generally unwilling to enter into relationships, they will avoid activities that involve significant interpersonal contact. The avoidant personality may yearn for acceptance, and is usually distressed by the lack of ability to relate comfortably with others. They view the self as feeling inferior and unacceptable, as having deficits, and are frightened by rejection. Their fictitious goal is to avoid humiliation – as life is unfair, they must be vigilant. The method is avoidance, and their impairments are depression, anxiety, and social phobia.

Behavioral, Interpersonal, and Cognitive Patterns

Avoidant PD (AVPD) is close to the anxiety disorders, since there is a degree of anxiety and stress, and low self-esteem is common. However, behaviors that produce the distress are relatively ego-syntonic. Their depression and anxiety are more related to the perceived rejection and criticism of others. This common disorder is seen more often in men. Any disorder in childhood that focuses on shyness predisposes one to the AVPD.

Other cognitions common to a person with AVPD include (a) if people really got to know me, they would see how inadequate (or odd) I really am, and they would reject me; (b) I am unable to cope with unpleasant people or situations; (c) not thinking about a problem or unpleasant situation or not trying to cope with it may allow it to go away; (d) you will never leave me because I will make sure I leave you first; and (e) nothing ventured, nothing failed.

8.2.8 Avoidant

The avoidant personality disorder is defined by social inhibition and shyness, by feel- ings of inadequacy, and by oversensitivity to possible negative evaluation (American Psychiatric Association, in press). Avoidant persons have such strong fears of criticism, dis- approval, or rejection that their social interactions are severely restricted: They are unwill- ing to participate socially unless certain of being liked, and tend to avoid work activities that involve interpersonal contact. In general, there is a sense of low self-esteem and of inferiority along with an extreme sensitivity to embarrassment, criticism, and rejection.

Avoidant personality disorder shares the symptom of lack of social contact with schiz- oid and schizotypal disorders, but the reasons for that lack of contact are very different: The avoidant person wants social contact but is afraid of rejection, whereas the schizoid or schizotypal person is completely indifferent to such contact.

6.21.1.5 Social Phobia and Avoidant Personality Disorder

Early on, APD and social phobia were defined as relatively distinct diagnostic entities. Social phobia referred to fear in circumscribed performance situations, whereas APD referred to more broad-based fear of social interaction. With the publication of DSM-III-R, changes in the diagnostic criteria were introduced which blurred the distinction between these two disorders. For example, the generalized subtype of social phobia, added in DSM-III-R, referred to fear in most social situations, a profile which previously would have excluded a diagnosis of social phobia. Also, the criteria for APD were modified such that there was now a greater emphasis on fear of negative evaluation and social discomfort, a central feature of social phobia. Whereas in DSM-III, five of five criteria had to be met for the diagnosis of APD, only four of seven were required in DSM-III-R, making it easier for the diagnosis to be awarded. This situation remains essentially unchanged in DSM-IV (see Heimberg, 1996, for a fuller discussion of the issues related to generalized social phobia and APD).

A number of articles have addressed the degree of overlap between generalized social phobia with and without APD (Brown et al., 1995; Herbert, Hope, & Bellack, 1992; Holt et al., 1992; Schneier, Spitzer, Gibbon, Fyer, & Liebowitz, 1991; Tran & Chambless, 1995; Turner, Beidel, & Townsley, 1992). Despite differences in sampling procedures, subtype definition, and diagnostic instruments, the degree of overlap was high, ranging from 25 to 89% in these six studies. Widiger (1992) concluded that generalized social phobia and APD were more alike than not and that the combination of generalized social phobia and APD probably represents a more severe manifestation of social phobia.

Differential response to treatment by generalized social phobics with and without APD might highlight distinctions between these two disorders, and the effects of treatment designed specifically for social phobia on the diagnosis of APD might further clarify this relationship. Brown et al. (1995) examined these issues in the context of cognitive-behavioral group treatment for social phobia. On the majority of outcome measures, there were no post-treatment differences between generalized social phobics with or without APD. On the remaining measures, social phobics with APD remained more severely impaired. Importantly, 47% (8 of 17) of the patients diagnosed with APD prior to treatment no longer met APD criteria following treatment. Hope, Herbert, and White (1995b) reported that APD did not differentially predict outcome of cognitive-behavioral group treatment for social phobia. However, in this study, subtype of social phobia and APD diagnosis were not considered simultaneously. Feske, Perry, Chambless, Renneberg, and Goldstein (1996) treated generalized social phobics with and without APD with a combination of behavioral techniques (exposure, relaxation, social skills training, and systematic desensitization). Although both groups significantly improved, generalized social phobics with APD began and ended treatment more impaired than social phobics without APD. This pattern of results was also evident at three-month follow-up.

These results lend further support to Widiger's (1992) conclusion noted above, that generalized social phobia and APD differ more quantitatively than qualitatively. In his review, Heimberg (1996) takes this argument a step further by questioning the appropriateness of separating these two diagnoses on to Axis I and Axis II. Most importantly for the clinical psychologist who may be treating generalized social phobics with and without APD is that response to treatment for these subjects appears to be similar.