Avoidant Personality Disorder Introduction Epidemiology and Phenomenology Causes Diagnostic Guidelines ICD-10 Criteria Diagnostic criteria (DSM-IV-TR) Differential Diagnosis Frequency Siblings Mortality / Morbidity Complications Prognosis Associated Features Relationships Employment Memory Historical Developments Review of Empirical Literature Studies Treatment Recommendations L Cognitive and Behavior Therapies L Psychodynamic Therapy L Interpersonal Therapy L Psychopharmacological Treatment L Group Therapy L Family Therapy L Medications Conclusions References

Avoidant Personality Disorder Causes, Frequency, Siblings and Mortality - Morbidity

Causes

• The exact cause of APD is unknown.
• The disorder may be related to temperamental factors that are inherited. Specifically, various anxiety disorders in childhood and adolescence have been associated with a temperament characterized by behavioral inhibition, including features of being shy, fearful, and withdrawn in new situations. Components of this temperament have been identified in infants as young as 4 months.
• Genetic factors have been hypothesized to cause APD and social phobia because both conditions are found more frequently in certain families. The exact mechanism of transmission is unknown, and phenotypic expression of any underlying genetic vulnerability may include other anxiety disorders.
• Although not specifically studied in cases of APD, traumatic experiences, parental overprotection, poor social skills, and parental anxiety have been found to be related to social anxiety.
• Retrospective studies of adults with APD report high levels of childhood emotional abuse (61%). Physical abuse, however, may be more closely linked with a diagnosis of another personality disorder or PTSD.
• A multifactorial model of causation is likely, with several of the above factors exerting variable influence in individual cases.

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 is 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 is 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 in its etiology & development is speculative & weak (Millon & Everly). However, there is some evidence that a timid temperament in infancy may predispose individuals to developing APD later in life (Kaplan & Sadock, 1991). While shyness appears to indicate underactivity, Kagan believes that this inherited tendency to be shy is 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, it is 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 is likely due to significant environmental influences (Millon & Everly).

As the individual gets older there are fewer mandatory (like school) activities that will force them to engage in the world. Their social connectedness can become more and more limited. Their avoidance behaviors can have severe consequences on their social and occupational functioning.

Frequency

• In the US: The frequency of APD in children is not known because current psychiatric practice is to avoid labeling children and adolescents with personality disorders and to describe their traits instead. However, in the adult general population, the prevalence is estimated to be 2.1–2.6%.
• Internationally: The international frequency has not been studied in children.
• Sex: APD is estimated to be equally common in males and females.

Associated features may include hypersensitivity to rejection and criticism.

Siblings

The order in which children are born within the family structure has a profound influence on their personality development. That is to say, the parents' expectations and treatment of the oldest child cannot be identical with that of the youngest one and so forth. The conclusion is that each child experiences a different environment within the same family.

Accompanying the obvious physical distinctions between male and female there is a complex biochemical system which not only distinguishes between the sexes in function, but also creates emotional differences which are further differentiated by the roles and expectations of the society in which they live.

Because of its gender and the fact that it necessarily views the environment from a different level of maturation, each child in a family will develop a distinctly individual personality.

Mortality / Morbidity

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.

• School refusal and poor performance: As many as one third of children who refuse to go to school may have significant social anxiety.
• Conduct problems and oppositional behavior: Many children with severe social anxiety refuse to participate in social activities and may have behavioral outbursts or panic attacks when placed in a social situation.
• Poor peer relations: Patients with APD often have few friends and refuse social overtures as children, behavior patterns that persist through adolescence and adulthood.
• Lack of involvement in social and nonsocial activities: Patients with APD demonstrate lower levels of participation in athletics, extracurricular activities, and hobbies than children with depression or other personality disorders.