The Evolutionary Neurodevelopmental Perspective

Perspectives such as biological, cognitive, interpersonal, and psychodynamic are useful for illuminating a given personality from a particular angle but do not permit holistic conceptions. Whereas most other personality disorders have ample historical precedent, the avoidant personality was originally formulated from Millon's biopsychosocial theory of personality in 1969 as the actively detached pattern, as distinctive from the passively detached schizoid personality. This conception shares many features with its modern evolutionary counterpart (Millon, 1990; Millon & Davis, 1996) that describes the avoidant as active and pain oriented in its evolutionary structure, while the schizoid is markedly passive, largely insensitive to either pleasure or pain, and only very moderately attuned to self over others in orientation. For schizoids, interpersonal detachment is ego-syntonic: Social isolation is simply solitude and does not trouble the individual. In contrast, the avoidant is actively detached. This sets up a conflict in which such individuals strongly desire involvement, love, and intimacy but fear exposing themselves to shame in seeking it. For them, social isolation is loneliness. Allison and Sean share this crucial characteristic though, in Sean, it is moderated through his intense interest in computers. Although he has not yet progressed to a point that he may recognize it, we could speculate that for Sean, computers are a substitute for real relationships. Therefore, he expresses his interpersonal needs far less than does Allison.

Before the crucial distinction between active and passive detachment, the central features characterizing the avoidant personality were scattered across the clinical literature. Although they have now been collected into a single syndrome, there is no strong parallel between past and contemporary conceptions, as there are for most other personality disorders. Because both avoidants and schizoids avoid interpersonal contact, they share the superficial feature of social detachment. Early object relations thinkers found this phenomenon to be particularly interesting (Fairbairn, 1940) but, paradoxically, emphasized withdrawal from the social world rather than the underlying reason for withdrawal, thereby mixing avoidant and schizoid features together. The error is understandable, as both personalities conceal their innermost thoughts and motives and both resist scrutiny and evaluation. The schizoid lacks the rich inner life of the avoidant, but neither offers the aspiring taxonomist much information. Accordingly, history classifies the two together. Some of this can be seen in Sean, who presents in a state of emotional numbness caused by intense fear. Table 6.1 summarizes the total avoidant personality in terms of its clinical domains.

The evolutionary model suggests several hypotheses in terms of the neurodevelopment of avoidant behavior. There are many structural elements and physiological processes that comprise the biophysical undergirding for the complex psychological functions of this pattern, such as affective disharmony, interpersonal aversiveness, and so on. Studies demonstrate that a higher than chance correspondence within family

TABLE 6.1 The Avoidant Personality: Functional and Structural Domains

Functional Domains

Structural Domains

Fretful

Alienated

Expressive Behavior

Conveys personal unease and disquiet, a constant timorous, hesitant, and restive state; overreacts to innocuous events and anxiously judges them to signify ridicule, criticism, and disapproval.

Self-Image

Sees self as socially inept, inadequate, and inferior, justifying thereby isolation and rejection by others; feels personally unappealing, devalues self-achievements, and reports persistent sense of aloneness and emptiness.

Aversive

Vexatious

Interpersonal Conduct

Distances from activities that involve intimate personal relationships and reports extensive history of social anxiety and distrust; seeks acceptance, but is unwilling to get involved unless certain to be liked, maintaining distance and privacy to avoid being shamed and humiliated.

Object-

Representations

Internalized representations are composed of readily reactivated, intense, and conflict-ridden memories of problematic early relations; limited avenues for experiencing or recalling gratification, and few mechanisms to channel needs, bind impulses, resolve conflicts, or deflect external stressors.

Distracted

Fragile

Cognitive Style

Warily scans environment for potential threats and is preoccupied by intrusive and disruptive random thoughts and observations; an upwelling from within of irrelevant ideation upsets thought continuity and interferes with social communications and accurate appraisals.

Morphologic Organization

A precarious complex of tortuous emotions depends almost exclusively on a single modality for its resolution and discharge, that of avoidance, escape, and fantasy; hence, when faced with personal risks, new opportunities, or unanticipated stress, few morphologic structures are available to deploy and few backup positions can be reverted to, short of regressive decompensation.

Fantasy

Anguished

Regulatory Mechanism

Depends excessively on imagination to achieve need gratification, confidence building, and conflict resolution; withdraws into reveries as a means of safely discharging frustrated affectionate as well as angry impulses.

Mood/ Temperament

Describes constant and confusing undercurrent of tension, sadness, and anger; vacillates among desire for affection, fear of rebuff, embarrassment, and numbness of feeling.

Note: Shaded domains are the most salient for this personality prototype.

Note: Shaded domains are the most salient for this personality prototype.

groups in social apprehensiveness and withdrawal behavior can be attributed in large measure to learning, but there is reason to believe, at least in some cases, that this correspondence may partially be assigned to a common pool of genotypic dispositions within families.

Some infants display hyperirritability, crankiness, tension, and withdrawal behaviors from the first days of postnatal life. The apparent "avoidant" constitutional disposition of these babies may then prompt rejecting and hostile attitudes from the caregivers. But it is neither necessary, nor sufficient, to be possessed of such a disposition. Normal, attractive, and healthy infants may also encounter parental devaluation, hypercriticism, and rejection. Reared in a family setting in which they are belittled, abandoned, and censured, these youngsters will have their natural robustness and optimism crushed and acquire in its stead attitudes of self-deprecation and feelings of social alienation. These harsh, self-critical attitudes may then have far-reaching and devastating consequences. The child who belittles his or her own worth will not be possessed of a self capable of healing psychological wounds or gaining rewards unobtainable from others. They are caught in a web of social and self-reproach, and they, themselves, become the agent of negative reinforcement.

Signs of avoidant behavior are usually, but not always, evident well before the child begins to participate in the give-and-take of peer relationships, school and athletic competitions, dating with its attendant anxieties, and so on. These early signs may reflect the operation of constitutional dispositions or attitudes and habits conditioned by the circumstances of family life. Whatever its origins, many school-age children already possess the social hesitations and aversive tendencies that will come to characterize them more clearly in later life. But for many other youngsters, the rudiments of social withdrawal and self-alienation have only developed minimally when they first encounter the challenges of peer-group activities. For them, the chances of enhancing their competencies and for developing the requisite skills for effective social adaptation remain good, unless they experience rejection, isolation, or the devastating ridicule that often can be meted out by their age-mates.

Contrast with Related Personalities

Avoidants share traits with several other personalities. Both avoidants and schizoids withdraw from the world of interpersonal relationships, though for different reasons. True schizoids are socially indifferent, or passively detached. They lack strong drives and emotions and appreciate few of the subtle nuances of human communication. In contrast, avoidants overflow with anxiety and are hypersensitive to even minor criticisms. Schizoids do not find interpersonal relationships reinforcing; avoidants find them punishing. Whereas the mental landscape of the schizoid is largely a vast, empty, unbroken plain, avoidants often develop a rich fantasy life as a means of compensating for their social inadequacies. Their need for affect and closeness may pour forth in poetry, be sublimated in intellectual pursuits, or be expressed in sensitively detailed artistic activities. In effect, they invent an imaginary world to substitute for the real world they avoid. Sean, for example, is deeply interested in programming languages. Because the computer always does exactly what he asks without judging him, it has become his playground.

Finally, the thought processes of both avoidants and schizoids sometimes seem disrupted or tangential. Given their scant drives, schizoids find neither life, thought, nor fantasy reinforcing. They have no interest in exploring the implications of a particular concept or developing a line of argument. For this reason, their thought processes are inherently diffuse. Seldom do they focus on any one idea for long. In contrast, avoidants are easily overloaded by external stimulation and may actively interfere with their own cognitive processes as a means of distracting themselves from overwhelming levels of anxiety or fear. Sean's stuttering, even in the safety of the therapy office, is a prime example, as is his inability to concentrate on his programming task knowing its social dimension.

The cognitive interference, pervasive social anxiety, and preoccupation with an internal fantasy world of some avoidants can also resemble the eccentricities, social detachment, and low self-esteem of the schizotypal personality. The cognitive intrusions of avoidants, however, rise and fall with their level of anxiety. When alone or with a few trusted intimates, the avoidant is often capable of sustained, goal-oriented cognition. In contrast, the schizotypal is characterized by a baseline of eccentricity, though this can sometimes be treated with the appropriate medications. Schizotypals are more dramatically bizarre and more prone to periods of psychotic decompensation. They may believe, for example, that they can read the thoughts of others, see through walls, or hear sounds emanating from far distant locations. Such ideas are highly unusual in an avoidant.

Both paranoids and avoidants are chronically tense and mistrustful, and both fear that they will suffer humiliation or embarrassment at the hands of others. Avoidants, however, believe their own inadequacies are the cause of social derogation, whereas paranoids believe that others are actively attempting to undo them. Both avoidants and paranoids are reluctant to confide in others. Avoidants, however, mainly fear embarrassment; paranoids feel that they will be betrayed and that the information conveyed will someday be used against them. Both personalities tend to be desperately lonely, a fact of which avoidants are often acutely aware. In contrast, paranoids see themselves as an island fortress under perpetual external assault and thereby disavow loneliness as an annoying vulnerability. Moreover, paranoids tend to be aloof, humorless, and aesthetically blunt, whereas avoidants show sensitivity, a good sense of humor, and often, a well-developed artistic capacity.

Finally, avoidants, dependents, compulsives, and negativists are all part of the so-called anxious cluster, personalities for whom anxiety is a prominent life concern. Avoidants and dependents are alike in sharing deep feelings of personal inadequacy but differ in their response to perceived inadequacy. When threatened with feelings of helplessness, dependents seek to bind others even closer to them by increasing their submis-siveness and attempting to please others all the more. In contrast, the avoidant is often very effective in nonsocial situations; the dependent is not. Avoidants run away at the first sign of negative evaluation; dependents stay and try to please. Both avoidants and compulsives share performance anxiety and a fear of evaluation, which they modulate with extraordinary self-control. Compulsives, however, are usually able to sublimate their anxiety into a preoccupation with rules, details, lists, and such; avoidants are more likely to simply withdraw from social venues.

Pathways to Symptom Expression

Avoidants are often thought of as the "anxious personality"; it is not surprising that they are highly vulnerable to the development of any number of clinical syndromes, more so than just about any other personality pattern. Accordingly, this section is somewhat longer than its counterparts in other chapters. As always, remember that there is a logic that connects the personality pattern with its associated Axis I syndromes. Avoidants who develop panic attacks, for example, like Allison, do so for reasons different from dependents. As you read the following paragraphs, try to identify the connection between personality and symptom.

Anxiety Disorders

Because their interpersonal skills are often sorely lacking due to chronic rejection, sharply critical caregivers, hereditary disposition, or the like, avoidant persons are highly inadequate in managing everyday social strains and challenges. Many of these individuals attempt to adjust by minimizing their social world as much as possible. However, this becomes a vicious, self-perpetuating circle, as the more insulated the person becomes, the more social phobia he or she manifests. Others who fail to adjust develop an anxiety disorder. Generalized anxiety and social phobia are probably the most frequent of the anxiety-spectrum disorders, though obsessive-compulsive disorder is also commonly found (Rodrigues & Del Porto, 1995). Panic attacks are also possible; just ask Allison.

Subjects with generalized anxiety disorder seem perpetually on edge and unable to relax, easily startled, tense, worried, preoccupied with possible calamities, and prone to nightmares. When asked what it is they fear, they report only a vague and diffuse awareness that something dreadful is imminent, though they are not sure what it is they dread or from where it will strike. Hypervigilance, an attention that is chronically active in searching for threat, even when the individual is alone, is probably the source of continuity between the avoidant personality and the clinical syndrome. In essence, the individual continues to scan the environment for sources of threat, even when other persons are not physically present. Without some concrete focus, it is possible that these individuals turn their ruminations inward, scanning their memories and recent interpersonal interactions for something that has been overlooked, for example.

The fear of social situations characteristic of generalized social phobia is so much a part of the avoidant that it is difficult to determine where the personality disorder ends and the clinical syndrome begins. The association is so close, in fact, that many researchers have questioned whether the two are separate syndromes (e.g., Fahlen, 1997) or whether they may represent points on the same continuum, both manifesting personality dimensions and clinical syndromes such as shyness, depressive symptoms, neu-roticism, introversion, social phobic avoidance, and social or occupational impairment (e.g., Rettew, 2000; van Velzen, Emmelkamp, & Scholing, 2000). Some (e.g., J. Reich, 2000) find extensive diagnostic criteria and treatment approach overlap and advocate reconceptualization of the Axis I and II constructs according to "empirical findings." Still others argue that their overlap is an artifact of the committee process through which the DSM is revised. The DSM-IV specifically asks clinicians to consider the additional diagnosis of avoidant personality where social phobia is generalized to most social situations.

Although both may be simultaneously diagnosed, several important distinctions should be remembered. First, the personality disorder includes a variety of traits that need not be associated with generalized social phobia. Avoidants, for example, typically attempt to maintain a social fa├žade of poise and self-control that conceals an inner anger, inherited from a developmental history that includes mockery for faults and foibles. In contrast, social phobias need not possess the full developmental picture expressed by the avoidant. Likewise, avoidants deeply wish for love and acceptance but doubt that such luxuries are possible, at least for them. Social phobics are not required to be distressed in this way.

Tentative therapy-outcome research suggests that the Axis I and II disorders frequently overlap, and those with a diagnosis of both avoidant personality disorder and social phobia are more impaired at the beginning of therapy, have more comorbid diagnoses, and remain more impaired after therapy and three months thereafter (Feske, Perry, Chamb-less, Renneberg, & Goldstein, 1996). This seems to suggest that avoidant personality includes additional enduring trait characteristics that social phobia does not, yet others have argued that the avoidant is only a more severe form of social phobia (Dahl, 1996; M. R. Johnson & Lydiard, 1995). The controversy is not yet settled and remains an important frontier in research on the personality disorders.

Obsessive-compulsive disorder is frequently found among avoidant personalities (Rodrigues & Del Porto, 1995). Obsessions are intrusive thoughts, impulses, or images that the individual experiences as stressful or anxiety provoking. The DSM-IV maintains that obsessions are usually unrelated to real-life problems and are experienced as unwanted, outside the person's control, and occurring unexpectedly. Fear of germ contamination is an example. In contrast, compulsions are unwanted behaviors, such as checking or washing rituals, which the person feels compelled to perform. If the compulsion is resisted, an inner sense of anxiety develops and increases. By giving these symptoms a functional interpretation, continuity can be established with the personality disorder. First, obsessions and compulsions serve to distract avoidants from constantly dwelling on their perceived inadequacies. Likewise, obsessive or compulsive preoccupations may counteract feelings of estrangement or depersonalization by providing especially withdrawn avoidants with thoughts and behaviors that assure them that there is some tangible reality to life. Disordered attention undoubtedly plays a role, though explaining why an obsession or compulsion takes on a particular theme seems to step outside the bounds of the cognitive perspective.

Physical Symptoms

Many personality disorders exhibit physical symptoms, referred to in the DSM-IV as somatoform disorders. In each case, the common thread is the presence of physical symptoms that cannot be explained by a medical condition or actual illness. Numerous factors make physical symptoms an ideal candidate for some hidden psychological purpose: All medical tests have some degree of error, physical perceptions are largely subjective, and medicine is an inexact science. Moreover, almost everyone has heard horror stories about incompetent physicians who overlook real problems, forcing their patients to complain even more loudly just to receive adequate care.

Physical symptoms can be used by avoidants to solve a number of coping problems. First, somatic concerns can be used to counter impending feelings of depersonalization or dissociation by assuring subjects of their own physical reality. In severe cases, social isolation may cause these bodily preoccupations to be elaborated into bizarre delusions. Second, somatic symptoms can be used as a distraction from an internal world of shame. If everyone is focused on the problem, they're at least not focused on the person. Third, unexplained feelings of fatigue or disabling pain may be used to justify social withdrawal, particularly in cases where significant others are at their limits and demand that the avoidant seek employment or otherwise engage the world on its own terms. Here, the physical problem functions as a distractor for all parties.

Although speculative, it appears that one physical symptom disorder, body dysmorphic disorder, might frequently present in the context of an avoidant pattern. Individuals with this condition are preoccupied with an imagined or very minor defect in their physical appearance, perhaps the shape of their nose, the size of their jaw, or a thinning hairline. So intense is their concern that they report feeling tormented and shamed. Some isolate themselves from society completely or travel only at night, when the darkness conceals their "ugliness." Some may spend hours examining their defect in a mirror. Obviously, the extreme avoidance of social engagement due to intense shame suggests characteristics of the avoidant personality. Stone (1993) presents such a case. Similarly, avoidants would not want to have some physical defect that might call attention to their other defects.

Dissociative Disorders

Avoidants, borderlines, and self-defeating (masochistic) personalities sometimes experience dissociative states (Ellason, Ross, & Fuchs, 1995, 1996). For the avoidant, feelings of self-estrangement may arise as a protective maneuver to diminish the impact of excessive stimulation, the pain of social humiliation, or a devalued sense of self. Without an integrated inner core to which experience can be anchored, events may seem disconnected, ephemeral, and unreal. Dissociative states can also be traced to the intentional use of cognitive interference, through which avoidants disconnect themselves from their own thoughts and feelings. Experiences of amnesia may sometimes occur as an expression of the rejection of self, a protective disowning of an individual's own identity.

Depressive Disorders

Avoidants are highly vulnerable to feelings of depression. Although Allison was diagnosed as experiencing panic attacks, her situation is objectively depressing. Though avoidants seek to insulate themselves from the fears and pains of interpersonal encounters, most are only partially successful. Moreover, isolation is bittersweet and conflict arousing, as avoidants continue to desire a successful and confident existence, intimate companionship, and freedom from self-contempt. The ideal self continues to seek expression, and critical internal voices continue to carp. Accordingly, most avoidants continue to feel unloved, alone, and ineffective. These feelings may be displayed either through full-blown depressive episodes or quietly endured periods of despondency and futility.

Schizophrenic Disorders

Historically, schizophrenia and the psychotic disorders have always represented a loosely bound collection of clinical symptoms. Despite considerable clinical observation and empirical research, it is not clear whether schizophrenia is one disorder or several, how restrictive the definition of the disorder should be, or how it might break down into subtypes. Some theorists believe that a genetic predisposition is a necessary factor (Meehl, 1962, 1990a, 1990b), whereas others hold that the disorder can occur through disordered family communication patterns alone. Despite problems in defining the disorder, most clinicians recognize the importance of distinguishing between positive and negative symptoms. Positive symptoms represent pathological exaggerations or distortions of normal cognitive functioning and include hallucinations, delusions, and disorganized speech and movement. Such persons often seem overaroused or hypersensitive. Negative symptoms represent deficits relative to normal behavior. Such persons are notable not so much for what they do, but for the lack of richness in their experience and existence. Their emotions seem flat, perhaps barely experienced. They have no purpose, goals, motives, interests, pursuits, hobbies, or passions, and they are not bothered by the absence of these things.

The distinction between positive and negative symptoms is similar to the distinction between the passively detached schizoid personality and actively detached avoidant personality (Millon, 1969) drawn earlier in this chapter. This suggests that schizoids are more likely to develop the negative symptoms of schizophrenia, and avoidants are more likely to develop the positive symptoms. Schizoid schizophrenics would thus display a chronic hyporeactivity and an absence of emotional depth. Cognitively, their lack of interest and motivation would cause them to drift aimlessly from one sparse and tangential thought to another. They would be completely apathetic about their lack of interpersonal involvement. In contrast, avoidant schizophrenics would display hyper-alertness and emotional turmoil. Cognitively, their tendency to distract themselves from pain and shame by interfering with their cognitive clarity would cause them to appear disorganized, fragmented, or incoherent. Interpersonally, they would tend to develop paranoid delusions as a defense against critical parental voices internalized during childhood. In effect, their fear of criticism develops into delusions of persecution, the idea that others are actively hunting for their faults, scheming to expose their inadequacies, or secretly planning a humiliating attack.

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