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Avoidant Personality
Avoidant Personality
AVOIDANT PERSONALITY
Avoidant personality disorder represents a Cluster C disturbance, defined in the DSM-IV as "a pervasive pattern of social inhibition, feelings
of inadequacy, and hypersensitivity to negative evaluation, beginning by
early adulthood and present in a variety of four or more of the following
contexts" (American Psychiatric Association, 1994, p. 664): the individual
(a) avoids work activities involving considerable contact with others, to
prevent disapproval or rejection; (b) hesitates or fails to establish relationships unless certain of acceptance; (c) is inhibited when intimate out of
apprehension over being shamed or ridiculed; (d) is preoccupied in social
contexts with criticism or rejection; (e) feels inadequate, which inhibits
social behavior in new contexts; (f) has low self-esteem and feels socially
incompetent and inferior to others; (g) fears interpersonal risk-taking out
of fear of being embarrassed.
To the observer an individual with avoidant personality may be hard
to distinguish from an individual with schizoid disorder in that both may
appear emotionally constricted or flat, withdrawn and unresponsive when
engaged. However, the individual with avoidant personality in fact is quite
different than the individual with schizoid personality on the three basis
polarities. Individuals with avoidant personality are strongly preservationoriented or pain-avoidant and relatively weak on the opposite pleasureseeking or enhancement polarity pole, whereas individuals with schizoid
personality are weak on both. Unlike individuals with schizoid personalities,
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those with avoidant personalities are strongly on the active pole of the
accommodation-modification continuum. The third polarity for the avoidant personality is the least defining of adjustment, because such individuals
are equal on self-other, individuation-nurturance motivations, whereas the
schizoid individual is more self-oriented. Thus, the prominent feature of
the avoidant individual is his or her active pursuit of escaping social and
psychic pain.
AVOIDANT SUBTYPES
In individuals with avoidant personalities with negativistic traits, underlying pessimism, anger, and resentment accompany their fears and social
anxieties. Such individuals may periodically criticize or complain of social
injustices, real or imagined, then exhibit mortification and apprehensive
withdrawal for their outbursts. Not surprisingly, individuals with avoidant
personalities may also develop prominent paranoid features, wherein a pervasive suspiciousness and a sense of mistrust characterize their social interactions. Such individuals may find it difficult to trust or positively respond to
encouragement and self-esteem-enhancing maneuvers given the sense that
others cannot be trusted. A mixture of avoidant with dependent character
features describes individuals caught between longings for close personal
relationships and a dread of abandonment combined with fears of intimacy
and a sense of mistrust. The interplay of these dynamics often generates
intense anxieties displaced into phobic concerns and fears that can be
circumscribed or compartmentalized so as to be more manageable. In addition, specific fears can be more socially acceptable than pervasive social
anxieties, and in turn elicit some degree of solicitousness and sympathy
from others, with less risk of rejection. The individual with avoidant personality with depressive traits will exhibit not only marked social aversion but
profound self-devaluation. Whereas other avoidant personality types may
maintain comparatively rich compensatory fantasy lives, these individuals
may feel disconnected from themselves, given their intolerance of their own
negatively viewed personal characteristics. To ease the burden of psychic
pain, they may disconnect from themselves, and if allowed, maintain a role
of passive observer of what limited social interactions are allowed.
AVOIDANT PERSONALITY
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PERPETUATING FEATURES
The primary coping mechanisms used by individuals with avoidant
personalities, that of vigilance and anticipation of social threat, ensures
maintenance of negative belief systems of a dangerous and rejecting world.
This in turn generates additional avoidant behavior patterns that maintain
a vicious cycle of approach-avoidance conflicts. The constriction that naturally ensues essentially removes the individual with avoidant personality
from opportunities for positive social events that could serve as corrective
experiences discontinuing the negative schemas built up from early traumas.
Whereas individuals without such personality disorders would routinely be
immersed in social experience and interaction, individuals with avoidant
personalities would have little distraction from their inner world of fears
and anticipations. What actual social experiences they may have had are
generally remote, providing little opportunity to update meager social skills.
This lack of any new social input or experience leaves them unable to
identify with groups or individuals who might provide different perspectives
from the alienation produced by their social history.
Not only dp individuals with avoidant personalities create selfperpetuating cognitive schemas and internalized social scenarios that selfmaintain their primary personality features, but their behavior may also
elicit social reactions reinforcing those views, by attracting individuals who
experience gratification at the humiliation and suffering of others. Individuals with avoidant personalities may also invite rejection by openly sharing
their self-contempt and anticipation of rejection. Although this might initially gain some reassurance from others, eventually others retreat or reject
in response to the insatiable needs for complete reassurance.
Conventional psychological treatment of individuals with avoidant personalities is to reduce their tendency to anticipate social-emotional pain and
pursue gratifications, overcoming the terrible approach-avoidance conflicts
that have left them miserable and desperate. A supportive, even unrestrained
empathic and nurturing orientation may be needed to overcome the deepseated mistrust and hesitancy manifested in their interpersonal relationships.
Given their fears of rejection or disapproval, these individuals may be reluctant
to share experiences that in their minds might invite ridicule, humiliation, or
contempt from others. Because of their low self-esteem, mistreatment on the
part of others toward them may be construed as deserved and therefore an
unfavorable reflection on them rather than the perpetrators of their pain.
Increasing positive experiences requires first reducing the anticipation
of pain so that sufficient approach behavior occurs to elicit some reinforcing
event. For the individual with avoidant personality this will require taking
chances, an antithetical consideration. Only if bolstered by unconditional
acceptance and encouragement is the individual with avoidant personality
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likely to risk additional rejection and social pain to create opportunities for
a different mode of social functioning. This requires use of both potentiating
and synergistic techniques, combinations of support, encouragement, modeling, social skills training, and pharmacotherapy.
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condition likely has been incorporated into their social behavior and selfimage, which are then inextricably tied up with their self-esteem. Intentional
ignoring of pain behavior may be particularly impactful to them, given their
hyperreactivity to any feedback that they might be doing something to incur
disapproval. Unresponsiveness to their displays may thus be experienced as
rejection, generating feelings of social panic, humiliation, and disorganized
apprehension rather than a reduction in the pain behavior itself. The effect
may be hurt withdrawal from the staff who ignored them; those treatment
team members are thus avoided and thereby lose their potentially reinforcing
properties. Accordingly with avoidant patients, it will be crucial to ensure
that they have learned alternative well behaviors to substitute for their pain
behaviors and have a means of securing the acceptance and approval of
their care providers.
Although addiction to analgesics is a common risk for chronic pain
patients, these agents also serve other purposes, such as sedation and mood
alteration. For patients with avoidant personalities, anxiety reduction and
diminishment of their typical state of hyperarousal may be an important
effect, especially needed if they are thrown into a controlled social environment where withdrawal is not tolerated and participation in socially based
activities is mandatory. Anxiety management training may be helpful, but
particularly so if it is accompanied by addressing the avoidant patient's
social anxiety, skill deficiencies, and low self-esteem. A patient advocateinterpreter of the treatment process who always remains in a nonjudgmental,
supportive role may be essential to diminishing some of the potential barriers
faced by these individuals.
In addition to reducing pain behavior, the goal of treatment is obviously
rehabilitation. For avoidant patients, this can mean return to responsibility
and social environments that were previously aversive or punishing when
they were fully healthy. They may anticipate the prospect of returning
to a similar situation in a diminished and presumably less capable state.
Preparatory goal setting involving selection of modest objectives where there
is a high probability of success will be necessary to contain their anxiety
level. Rehearsing anticipated situations and work-hardening experiences
with supportive, encouraging staff who are well informed about the patient's
sensitivities and characteristics will help minimize the avoidant patient's
tendency to become deflected with minor setbacks and interpersonal distractions. It must be remembered that these individuals are especially sensitive
to false prospects of improvement in their lives. For them to regain some
functioning from an injury or illness in the face of persisting negative
aftereffects (pain) represents a significant challenge for the health care
provider. Prognostic forecasts should not be overly optimistic, because this
likely will only be threatening. Rather, recognition, even emphasis of significant remaining handicaps, particularly during periods of gain, may be
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important to give the avoidant patient a sense that lack of progress and
setbacks are acceptable and not a basis for derision or rejection. For these
individuals, to feel there is an acceptable explanation for any lack of success
in regaining normal functioning and that effort, not success, is (socially)
rewarded may serve as protection from the intense fear of failure that otherwise may consume them.
Diabetes
Being anxiety-prone, stressful situations for individuals with avoidant
personalities could contribute to altered glucose metabolism. Dealing with
fluctuations in the illness that are not diet-caused can be a source of interpersonal tension and recrimination with the health care providers, who may
not initially consider alternative causes and attribute the difficulty to patient
misbehavior. The risk is that such misunderstanding by health care providers
can result in a sense of rejection potentially strong enough that the severely
avoidant patient might exit the care setting. Once rejected, they may remain
fearful about seeking alternative care, which they would anticipate as also
ultimately rejecting. Like individuals with schizoid disorders, individuals with
avoidant personalities might drop out of contact not out of indifference but
to escape from a potentially noxious social situation. A patient, accepting
orientation by the physician combined with discussion and monitoring of the
different contributing factors in problematic blood-sugar regulation should
help counter these potential risks to the care of the avoidant individual.
Neurological Diseases: Epilepsy, Multiple Schlerosis,
Parkinson's Disease
Epilepsy for avoidant patients could represent a convenient escape
from burdensome anxieties and responsibilities, justifying social withdrawal,
but it would also likely increase their social and self-alienation, making
them feel even more vulnerable and inadequate, limited and restricted.
Public episodes would be experienced as particularly humiliating. Such
patients' chronic anxiety might also make their seizure thresholds lower and
conditions more difficult to manage given their stress-proneness. Erratic
medication monitoring caused by their ruminative, distractible cognitive
style might also contribute.
Multiple sclerosis may be an unobtrusive illness that creates a chronic
sense of uncertainty to the patient, who may experience episodes of sensory
or motor dysfunction (e.g., blurred vision, weakness) disruptive to functioning. Any experience of this kind may produce more intense feelings of
vulnerability, inadequacy, and self-loathing. Organic personality changes
may produce exaggeration of preexisting anxiety-prone characteristics,
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CONCLUSION
Patients with avoidant personality characteristics, as with other patients, will have good intentions to do "what is right" in health care contexts.
However, their primary goal rather than good health care will be avoiding
censure and disapproval of those with whom they are dealing. Where there
is little to do, then practitioners will be pleased and these patients will be
reasonably comfortable. However, if the interactive requirements and the
treatment regimen for effective health care management is complex or
difficult or aversive (a brusque practitioner), then the natural apprehensiveness and fear of rejection of these patients will emerge as a complicating
factor. These patients' coping responses are predominated by escapeavoidance behavior, reducing communication opportunities to seek needed
support, clarification of needed medical information, and efficient tracking
of symptoms. Under threat these individuals will retreat into a private,
anxious world cut off from corrective opportunities, distracted by fears of
rejection, thoughts of unworthiness and self-loathing. Individuals with these
characteristics have little opportunity to generate needed social support for
Avoidant Personality
Social Support
too fearful to recruit aid
overreliant on
existing sources
->
Coping
distracted, fragmented
avoiding disapproval
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AVOIDANT PERSONALITY
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