Objectives

• What are the DSM-IV criteria for the avoidant personality?

• The sensitive, vigilant, and hesitating personalities are normal variants of the avoidant. Describe their characteristics and relate them to the more disordered criteria of the DSM-IV.

• How does the avoidant personality manifest itself in a collectivist society?

• Explain how different personality styles combine to form each of the subtypes of the avoidant personality.

• List the contributions of the psychodynamic perspective to the conceptual development of the avoidant personality.

• What is phobic character?

• Explain how the content and structure of cognition interact in the avoidant to perpetuate this disorder.

• What is cognitive interference?

• What are the core beliefs of the avoidant?

• Because of their fears and anxieties, avoidants withdraw from interpersonal contacts. What are some of the consequences of their interpersonal reticence?

• How does anxiety inhibition contribute to the development of the avoidant personality?

• Avoidants share characteristics with other personality disorders. List these other disorders and explain the distinction between each and the avoidant.

• Avoidants are particularly prone to anxiety disorders. Are social phobia and avoidant personality distinct disorders?

• List therapeutic goals for the avoidant personality.

You may have seen individuals in your classes who seem to earnestly desire participation in discussions, but they say little to nothing and seem awkwardly self-conscious on those very rare occasions when they speak a few words. Perhaps you have noticed someone at a party who shows up early and stays late but spends most of the time anchored to a corner of the room, hoping someone else will approach him or her to make conversation. If you are that person who approaches, you will likely notice the person's immediate discomfort upon your initiating even the most pleasant, innocuous, non-threatening conversation. You might wonder what keeps people this socially "wrapped up" and defended and how such individuals perceive themselves and the world they share with you. You might correctly perceive that they are filled with chasms of self-doubt, they intensely fear any sort of humiliation, and they would not dare knowingly (or even unwittingly) expose themselves to other people or a competitive and cut-throat world for which they feel they are no match.

These individuals demonstrate the avoidant personality pattern. They may have just one or two trusted friends, perhaps a spouse or partner, or even a sole family member. Few others, if any, would be able to pass their strict tests of uncritical support and acceptance to gain access to their more private circle of existence. Does this mean that such a person is content with this very secretive, isolated way of life? Quite the contrary. Their pain wrought from loneliness and seclusion hurts them to the core of their existence, but rather than allow themselves to be vulnerable to the "inevitable" social humiliation that would follow from their perceived incompetence and awkwardness being put on naked display, they take their silent, lonely pain and make themselves nearly invisible—out of the trajectory of others' "harsh but deserved" criticisms. Because of their way of exaggerating potential for embarrassment, they do more to themselves than forego social enhancement. They resist any life change that may bring them more openly into the public eye, including occupational promotions and other life rewards. While they may deeply wish for love, genuine intimacy, and greater life enjoyment or satisfaction, their souls are seen as so disgraced that they must withdraw into a private world of shame, where they can at least be alone with their inadequacies.

Consider the case of Allison (see Case 6.1), who seems to meet diagnostic DSM-IV criteria for avoidant personality disorder in a rather straightforward manner. This pattern exhibits social inhibition caused by deep feelings of inadequacy and fears of ridicule and rejection. As it is virtually impossible to predict what others may think of them and nearly as difficult to know how they themselves should "ideally" behave, avoidants are in a constant state of threat and alarm when they must interact with others. They are hypersensitive to negative evaluation, doubt that they have anything to offer others, and thus find it terrifying to interact with anyone they do not already know. This may be an apt description of Allison's internal, subjective existence. Hypersensitive to a marked degree, she panics on having to interact, as she quickly feels that the critical eyes of everyone are on her. Her self-consciousness convinces her that others are taking great pains to notice her; this possibility is recycled unremittingly in her mind, her anxiety snowballs, and she feels forced to flee. Although this is typical of avoidant patterns, it is not exclusive to them. What is unique, however, is how this is experienced. Whereas some personalities, such as the narcissist or histrionic, may find the spotlight irresistible, avoidants dread it and must take flight for the relative safety of obscurity. Life is left with very little joy, but at least it holds no pain.

Similar themes permeate many, if not all, aspects of the avoidant person's life. Fears of evaluation will likely cause avoidants to restrict their occupational activities

Allison Is a 22-year-old undergraduate at a local community college. She is clearly shy and uncomfortable in the clinical interview, but nevertheless complains of panic attacks so immobilizing that her contact with the outside world is limited to a bare minimum. With a new semester starting, she does not know if she will be able to attend classes.1 The pattern is always the same. Suddenly she notices her heart quicken, then she begins to sweat as the fear of an attack grows, then her heart begins to race faster and faster and she is overtaken by panic.

There is little joy in Allison's life. She tries to work each day, takes care of necessary errands, and shops for food every few weeks. Generally, she lets things accumulate and then tries to do them all at once, to get it over with. In the past, she occasionally enjoyed volunteer work at a botanical garden, but has never held a real job. When asked about her social life, she has difficulty naming friends. "My fear," she states, "is that others won't like me if they really find out about the real me!" Although her words are deeply felt, she never makes eye contact with the interviewer. She concedes that although others may be capable of succeeding in the world, she desperately wants to be left alone. Even when she is just sitting in class, she has difficulty believing that others who are laughing are not making fun of her.

Allison's history goes far toward making sense of her symptoms. She has been reminded many times that her birth was an accident, something unpleasant that her mother and father "had to go through." She cannot recall a time when she felt loved by her parents. "Not that they were neglectful," she quickly points out, "but I always felt like a burden to them." Life at home was without warmth or joy, with much time spent fantasizing alone in her room, something she still does today. Worse, her parents, themselves highly successful, had high expectations for her but were often excessively critical, even of the smallest mistakes. Because of her shyness, she had to endure hours of merciless teasing from the other children, apparently the origin of a crippling self-consciousness that has followed her ever since. Unable to defend herself, she withdrew socially, as if to become smaller and less noticeable to others.

When asked about relationships, Allison refers to her only boyfriend, when she was a high school senior. "Even then," she reflects, "I was afraid to be myself or voice any kind of opinion of my own. I was afraid he would dump me." When asked about marriage, Allison admits she has dreams of being accepted unconditionally, but doubts that it will ever happen. Instead, she prefers to be alone, "where it's safe, where no one can see your faults, much less judge you or criticize you for them." "If you keep with what you know," she says, "you at least don't have to worry about embarrassing yourself."

1 Numbers mark aspects of the case most consistent with DSM criteria, and do not necessarily indicate that the case "meets" diagnostic criteria in this respect.

Avoidant Personality Disorder DSM-IV Criteria

A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

(1) avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection

(2) is unwilling to get involved with people unless certain of being liked

(3) shows restraint within intimate relationships because of the fear of being shamed or ridiculed

(4) is preoccupied with being criticized or rejected in social situations

(5) is inhibited in new interpersonal situations because of feelings of inadequacy

(6) views self as socially inept, personally unappealing, or inferior to others

(7) is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing

Reproduced with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Copyright 1994 American Psychiatric Association.

(see criterion 1). Their job suffers under imagined nightmares that their performance will somehow be defective or inadequate. Depending on the severity, they may simply quit or may remain stuck in positions with no challenge, where adequacy is easy. As we saw, Allison formerly volunteered at the botanical gardens. She probably enjoyed its beauty and tranquility and was not expected to perform to any particularly difficult measure, as would an employee. Thus, Allison created her own means of escape. If her fears became too great, she could simply say that school or something else in her life was more important, and everyone would understand. It seems, however, that her fears have intensified to the point that she can no longer tolerate the demands of school. More than likely, Allison has never spoken to any of her professors, who are required to grade her and note areas in which she may improve. Allison has become far too sensitive for this process, and we may speculate that she is unable to profit from feedback of almost any kind, whether good or bad. Therefore, Allison plays everything safe.

There is only one way that she may ever involve herself with others: She must be absolutely certain that she will be liked (see criterion 2). This is, however, extremely difficult to accomplish. She has an abiding faith in her own defectiveness, in her ability to bring shame on herself simply by existing. Whereas most of us are insecure about something, Allison's insecurities constitute her perceived reality. Accordingly, the notion that someone might like her and might accept her for who and what she is, is virtually unthinkable. To develop a friendship, Allison needs repeated overtures of nurturance and assurance. Moreover, she needs consistency. Let some small criticism slip just once, and like a frightened turtle, she recoils in terror, withdrawing to the sanctity of her shell, shutting out the world. Because the shell is so thick, few people ever gain the trust of an avoidant person.

Even when Allison does overcome her hypersensitivity long enough to let someone in, her belief in her own imagined inadequacies has another unfortunate consequence: Allison is afraid to be herself. To grow, relationships must balance between self-conscious commitment and spontaneity. But Allison can't afford to be herself because she is hyper-aware of the faults and imperfections all humans carry (which she feels are hers and hers alone), and the price of authenticity is too high (see criterion 3). Were she in a relationship, Allison would find it extremely difficult to reveal her true self, to share a secret, or even to tell her partner about her real likes and dislikes. Any of these could poison the thin illusion of genuine companionship that her insecurities afford and leave her with nothing. So Allison sacrifices the potential of a romance for a steady trickle of togetherness, which is at least more certain. There are no flings of infatuation, weekends away, or sweep-you-off-your-feet dreams-come-true for Allison. No one would ever like her that much, or so she believes; if someone did like her, it would only be because she had the wisdom never to show her true self. She sees herself just as her parents likely saw her— as a burden that no one would want.

These descriptions constitute Allison's work, school, and relational perceptions; these are but a subset of her experience. Avoidant personalities feel this way in nearly all social situations (see criterion 4). Wherever they go, they feel people always have expectations of them. They fear criticism and rejection, as the DSM notes, but they also live in fear of simply disappointing others. That is, rejection doesn't need to be actually voiced to summon up the fears of people like Allison. Just the idea that someone might privately judge them as having failed or fallen short is enough to make avoidants want to disengage. Worse is the possibility that someone might take a stern attitude toward them, presuming to judge them from a position of authority, where the verdicts are more powerful and absolute in their condemnation.

It is of little wonder, then, that avoidants are inhibited in interpersonal situations (see criterion 5). Feelings of inadequacy make them shrink back, as Allison did, "to become smaller and less noticeable to others." We often think about pathology in connection with shutting others out, but avoidants take the additional measure of shutting themselves in. For them, the key is to limit exposure. By revealing very little of themselves, avoidants leave little that can be attacked. The philosopher Hegel said, "To be is to be perceived." For Allison and others like her, however, the existential truth is just the reverse. The only way to be is not to be perceived, at least if you want to be safe and salvage a marginal quality of life. Accordingly, whereas some personalities, such as the narcissist and histrionic, surge forward in social situations, seizing the limelight and demanding admiration, avoidants inhibit themselves and withdraw to a niche where they can at least be alone and, therefore, feel some comfortable. Avoidants should always be aware of others, but others should never be aware of the avoidant.

As with many personality disorders, positive change and improvement of life circumstances is very difficult for the avoidant person. Personal growth requires a measure of risk. Because Allison sees herself as inept and unappealing (see criterion 6), it is doubtful that she will ever, as humanistic psychologists would say, actualize her potential in life. To expand our horizons, we must push the boundaries. Or, as the old adage goes, experience is the best teacher. Avoidant personalities, however, refuse to take risks that might leave them open to public view (see criterion 7). They can be highly creative in the privacy of their apartment or become superheroes in their own fantasy life, but in the real world, it's best not to attempt anything that might bring attention to themselves. When you're inadequate and you know it, attention becomes the enemy.

As in the previous chapter, we now move from this introductory case example of an avoidant personality to examine conceptual, theoretical, and historical issues. First, we compare normality and abnormality; then we move on to the various incarnations and admixtures of avoidant patterns. Psychodynamic, cognitive, interpersonal, and biological perspectives, the core of the science of personality, are then described. By seeking to explain what we observe in character sketches such as Allison's, we move beyond literary anecdote and enter the domain of theory. As always, we present history and description side by side, noting the contributions of past thinkers, each of whom tends to bring into focus a different aspect of the disorder. Developmental hypotheses are also reviewed but are tentative for all personality disorders. Next, the section "Evolutionary Neurodevel-opmental Perspective" shows how the existence of the personality disorder follows from the laws of evolution. Also included are a comparison between the avoidant and other theory-derived constructs and a discussion of how avoidant personalities tend to develop Axis I disorders. Finally, we survey how the disorder might be treated through psychotherapy, again organizing our material in terms of classical approaches to the field: the cognitive, interpersonal, and psychodynamic perspectives.

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