Which behaviors are expected in patients with avoidant personality disorders?

Many individuals are characterized by specific personality traits from joyous and extroverted to introverted, brash, bubbly and solemn. Personality traits become personality disorders when these long-lived behavioral traits cause problems with work and relationships. Avoidant personality disorder is a psychiatric condition characterized by a lifelong pattern of extreme social inhibition, feelings of inadequacy, and sensitivity to rejection. People with avoidant personality disorder may avoid work activities or decline job offers because of fears of criticism or disappointment from others. The avoidant behavior typically starts in infancy or early childhood with shyness, isolation, and avoidance of strangers or new places. Most people who are shy in their early years tend to grow out of this behavior, but those who develop avoidant personality disorder become increasingly timid as they enter adolescence and adulthood. It is possible that individuals with avoidant personality disorders were bullied, neglected or abused in childhood, which caused them to isolate themselves from others.  Having a high sensitivity to rejection can cause individuals to not have many friends, to not ask for a raise at work, to not voice their opinion around others and to not ask questions. Statistics show that approximately 2 percent of the population has avoidant personality disorder and this disorder equally affects both men and women.

Signs and symptoms of avoidant personality disorder

• Easily hurt by criticism or disapproval
• No close friends
• Reluctance to become involved with people
• Avoidance of activities or occupations that involve contact with others
• Shyness in social situations out of fear of doing something wrong
• Exaggeration of potential difficulties
• Showing excessive restraint in intimate relationships
• Feeling socially inept, inferior, or unappealing to other people
• Unwilling to take risks or try new things because they may prove embarrassing

A desire to fit in

Despite their isolation, a person with avoidant personality disorder actually does desire affection and acceptance. They may even fantasize about idealized relationships with others and may feel ashamed of who they are because of how they were treated in childhood. Avoidance is a coping mechanism many use as a way to overcome the hurdles experienced in childhood, however, avoidance also feeds fear and the more you avoid what you fear, the more you fear it creating a viscous and unhealthy cycle.
Although there is no cure for personality disorders, therapy can have a positive impact when used in the appropriate environment. Cognitive-behavioral therapy is the treatment of choice for avoidant personality disorder because the emphasis is on changing thinking patterns as well as modifying behavior. Emphasis is placed on helping the individual become desensitized to the stimuli (social situations) that causes them fear resulting in avoidance and isolation. Behavior modification includes learning the social skills necessary to function in society:

• Making eye contact with people
• Learning to greet people with a smile and rehearsing common verbal interactions between people
• Learning how to be assertive in ways that are appropriate
• Learning what to say or how to respond in a variety of social situations
• Learning and rehearsing how to carry on common everyday conversations with people.

Personality is the way of thinking, feeling and behaving that makes a person different from other people. An individual’s personality is influenced by experiences, environment (surroundings, life situations) and inherited characteristics. A person’s personality typically stays the same over time.

To be classified as a personality disorder, one's way of thinking, feeling and behaving deviates from the expectations of the culture, causes distress or problems functioning, and lasts over time.1 The pattern of experience and behavior usually begins by late adolescence or early adulthood and causes distress or problems in functioning. Without treatment, personality disorders can be long-lasting.

There are 10 specific types of personality disorders in the DSM-5-TR. Personality disorders are long-term patterns of behavior and inner experiences that differ significantly from what is expected. They affect at least two of these areas:

• Way of thinking about oneself and others
• Way of responding emotionally
• Way of relating to other people
• Way of controlling one’s behavior

Types of Personality Disorders

• Antisocial personality disorder: a pattern of disregarding or violating the rights of others. A person with antisocial personality disorder may not conform to social norms, may repeatedly lie or deceive others, or may act impulsively.
• Avoidant personality disorder: a pattern of extreme shyness, feelings of inadequacy, and extreme sensitivity to criticism. People with avoidant personality disorder may be unwilling to get involved with people unless they are certain of being liked, be preoccupied with being criticized or rejected, or may view themselves as not being good enough or socially inept.
• Borderline personality disorder: a pattern of instability in personal relationships, intense emotions, poor self-image and impulsivity. A person with borderline personality disorder may go to great lengths to avoid being abandoned, have repeated suicide attempts, display inappropriate intense anger, or have ongoing feelings of emptiness.
• Dependent personality disorder: a pattern of needing to be taken care of and submissive and clingy behavior. People with dependent personality disorder may have difficulty making daily decisions without reassurance from others or may feel uncomfortable or helpless when alone because of fear of inability to take care of themselves.
• Histrionic personality disorder: a pattern of excessive emotion and attention-seeking. People with histrionic personality disorder may be uncomfortable when they are not the center of attention, may use physical appearance to draw attention to themselves or have rapidly shifting or exaggerated emotions.
• Narcissistic personality disorder: a pattern of need for admiration and lack of empathy for others. A person with narcissistic personality disorder may have a grandiose sense of self-importance, a sense of entitlement, take advantage of others or lack empathy.
• Obsessive-compulsive personality disorder: a pattern of preoccupation with orderliness, perfection and control. A person with obsessive-compulsive personality disorder may be overly focused on details or schedules, may work excessively, not allowing time for leisure or friends, or may be inflexible in their morality and values. (This is NOT the same as obsessive-compulsive disorder.)
• Paranoid personality disorder: a pattern of being suspicious of others and seeing them as mean or spiteful. People with paranoid personality disorder often assume people will harm or deceive them and don’t confide in others or become close to them.
• Schizoid personality disorder: being detached from social relationships and expressing little emotion. A person with schizoid personality disorder typically does not seek close relationships, chooses to be alone and seems to not care about praise or criticism from others.
• Schizotypal personality disorder: a pattern of being very uncomfortable in close relationships, having distorted thinking and eccentric behavior. A person with schizotypal personality disorder may have odd beliefs or odd or peculiar behavior or speech or may have excessive social anxiety.

Diagnosis of a personality disorder requires a mental health professional to evaluate long-term patterns of functioning and symptoms. Diagnosis is only applicable to individuals 18 or older. People under 18 are typically not diagnosed with personality disorders because their personalities are still developing. Some people with personality disorders may not recognize a problem. Also, a person may have more than one personality disorder. An estimated 9 percent of U.S. adults have at least one personality disorder.2

Treatment

Certain types of psychotherapy have shown to be effective for treating personality disorders. Ideally, during psychotherapy, an individual can gain insight and knowledge about their disorder, what is contributing to symptoms, and get to talk about thoughts, feelings and behaviors. Psychotherapy can help a person understand the effects of their behavior may be having on others and learn to manage or cope with symptoms and to reduce behaviors causing problems with functioning and relationships. The type of treatment will depend on the specific personality disorder, how severe it is, and the individual’s circumstances.

Commonly used types of psychotherapy include:

• Psychoanalytic/psychodynamic/transference-focused therapy
• Dialectical behavior therapy
• Cognitive behavioral therapy
• Group therapy
• Psychoeducation (teaching the individual and family members about the diagnosis, treatment and ways of coping)

There are no medications specifically used to treat personality disorders. However, in some cases, medication, such as antidepressants, anti-anxiety medication or mood-stabilizing medication, may be helpful in treating some symptoms. More severe or long-lasting symptoms may require a team approach involving a primary care doctor, a psychiatrist, a psychologist, a social worker and family members.

In addition to actively participating in a treatment plan, some self-care and coping strategies can be helpful for people with personality disorders.

• Learn about the condition. Knowledge and understanding can help empower and motivate.
• Get active. Physical activity and exercise can help manage many symptoms, such as depression, stress and anxiety.
• Avoid drugs and alcohol. Alcohol and illegal drugs can worsen symptoms or interact with medications.
• Get routine medical care. Don’t neglect checkups or regular care from one's family doctor.
• Join a support group of others with personality disorders.
• Write in a journal to express one's emotions.
• Try relaxation and stress management techniques such as yoga and meditation.
• Stay connected with family and friends; avoid becoming isolated.

Source: Adapted from Mayo Clinic, Personality Disorders

Family members can be important in an individual’s recovery and can work with the individual’s health care provider on the most effective ways to help and support. But having a family member with a personality disorder can also be distressing and stressful. Family members may benefit from talking with a mental health provider who can provide help coping with difficulties.

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