Anxious Avoidant Personality Disorder

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Classification according to ICD-10
F60.6 Anxious (avoidant) personality disorder
ICD-10 online (WHO version 2019)

The anxious avoidant personality disorder (ÄVPS) is a mental disorder . It is characterized by feelings of tension and anxiety, insecurity and inferiority . Other names for the disorder are self-insecure personality disorder (SUP) or avoidant-self-insecure personality disorder (historically also hypersensitive personality disorder ).

There is a constant longing for affection and acceptance while at the same time being hypersensitive to criticism and rejection. This sensitivity to rejection is often associated with limited ability to form relationships. Those affected tend to overemphasize the potential dangers or risks of everyday situations, or even avoid certain activities.

description

It is characteristic of fearful avoidant personalities that they feel insecure, inhibited, unattractive and inferior and avoid social contacts for fear of criticism, rejection and ridicule. In doing so, they often find themselves in social isolation and need special support in being lured out of their reserve. Their low self-confidence is usually seen positively or not at all by others because they do not push themselves to the fore, are modest, “easy to care for” and reliable. They are typically easy to influence and difficult to say "no".

It is not uncommon for these people to enjoy a high reputation among their fellow men. Because they often try to compensate for their supposed inadequacies with good professional performance or a high level of self-sacrifice. Typical are a social inhibition as well as feelings of incompetence, shyness , easy blushing and quick embarrassment and constant self-doubt. Often there is a pronounced sensitivity to negative criticism, humiliation and shame. Eye contact is often avoided in conversations. In social contacts, they often seem tense, inhibited, tormented, and distant. The flow of speech is often inhibited.

Diagnosis

ICD-10

In ICD-10 is personality disorder anxious avoided included under code F60.6. At least four of the following properties or behaviors must be present for diagnosis:

  1. persistent and extensive feelings of tension and concern;
  2. Conviction of being socially awkward, unattractive or inferior in comparison with others;
  3. excessive worry of being criticized or rejected in social situations;
  4. personal contacts only if there is certainty of being liked;
  5. restricted lifestyle due to the need for physical security;
  6. Avoidance of professional or social activities that require intensive interpersonal contact for fear of criticism, disapproval or rejection.

Hypersensitivity to rejection and criticism can be additional characteristics.

DSM-5

In the current DSM-5 , the avoidant self-insecure personality disorder is recorded in the chapter on personality disorders in section II under 301.82. The introduction to the DSM is essentially due to Theodore Millon . It is a profound pattern of social inhibition, feelings of insufficiency and over-sensitivity to negative assessments. It starts in early adulthood, and the pattern shows up in different situations. At least four of the following criteria must be met:

  1. Out of fear of criticism, disapproval or rejection, avoids professional activities that involve closer interpersonal contacts.
  2. Reluctant to get involved with people unless he / she is sure that he / she is liked.
  3. Shows restraint in intimate relationships for fear of being embarrassed or ridiculed.
  4. Strongly taken up by being criticized or rejected in social situations.
  5. Is inhibited in new interpersonal situations due to feelings of inadequacy.
  6. Believes himself to be socially awkward, personally unattractive, and inferior to others.
  7. Exceptionally reluctant to take personal risk or undertake any new venture because doing so could prove shameful.

DSM-5 alternative model

The alternative model of the DSM-5 in Section III suggests the following diagnostic criteria:

A. Moderate or severe impairment of the function of the personality, which is manifested by typical difficulties in at least two of the following areas:

  1. Identity: Low self-esteem associated with the self-assessment of being socially awkward, personally unattractive or inferior; pronounced feelings of shame.
  2. Self-control: Unrealistic expectations of yourself, combined with a reluctance to pursue your own goals, to take personal risks or to take on new ventures if these involve interpersonal contacts.
  3. Empathy: Strong preoccupation with and sensitivity to criticism or rejection, combined with the distorted assumption of being viewed negatively by others.
  4. Proximity: reluctance to get involved with people unless one is sure of being liked; limited mutual exchange in close relationships for fear of being embarrassed or ridiculed.

B. Presence of at least three of the following problematic personality traits, one of which is (1) anxiety:

  1. Anxiety: An intense feeling of nervousness, tension, or panic, often in response to social situations; Concern about negative effects of past unpleasant experiences and about possible negative developments in the future; anxious feelings, apprehension, or feeling of threat when feeling unsafe; Fear of shame.
  2. Social withdrawal : reluctance in social situations; Avoidance of social contacts and activities; lack of social contact.
  3. Anhedonia : lack of joy, commitment, or energy in the things of everyday life; Impairment of the ability to have lust and be interested in things.
  4. Avoiding closeness: Avoiding close relationships, love relationships, interpersonal ties, and intimate sexual relationships.

Criticism and appreciation

From Rainer Sachse comes the general criticism of the diagnosis of personality disorders that empirically proven criteria are not taken into account, that no central criteria are defined, although it is empirically and theoretically clear that not all characteristics are equally relevant. Motives and schemes are also not taken into account. The criteria are also not empirically validated and are therefore arbitrary. The clusters of the DSM are neither empirically founded nor theoretically comprehensible and would summarize disturbances that are at most superficially similar (Sachse, 2019, p. 101).

For Peter Fiedler , the criteria of the "more recent" alternative model (described above) in the DSM-5 for the dimensional diagnosis of personality disorders offer "the most differentiated perspective on the disorder" of the AEVPS.

Subtypes

According to a study by Alden and Capreol (1993), patients with avoidant self-insecure personality disorder can be divided into the following two subtypes:

Cool-aloof
This group can be described as “cool-distant” and “socially avoidant ” (cold-avoidant) ; It is characterized by distrust and problems expressing warm feelings.
Resilient-exploitable
It is characteristic of the “ exploitable-avoidant” group that those affected feel or are actually exploited by others and find it difficult to point out other limits. In the sexual area this can u. May encourage abuse by others.

Demarcation

Before a diagnosis can be made, the symptoms must be differentiated from those of other disorders ( differential diagnosis ). Insecure personalities, for example, actively withdraw, i.e. consciously avoid social relationships, while people with schizoid personality disorder (SPS) withdraw passively. The biggest difference is that the former is caused by low self-confidence and fear of being rejected by other people, which is less of a concern with the latter. However, some researchers believe that schizoid and fearful-avoidant personalities are just different variants of the same personality disorder. There is also evidence of genetic similarities between the two.

A main problem with differential diagnostics is the considerable overlap of criteria with social phobia . Social phobics usually have narrowly defined fears (for example, of exams, public speaking), while those of fearful-avoidant personalities are extended to many different situations. In addition, the anxiety-avoidant personality disorder is experienced to a greater extent than I-synton : This means that those affected regard their anxious thought patterns and their insecure behavior as an integral part of their personality despite the stress of suffering. Social phobics, on the other hand, usually experience their symptoms more clearly than a disorder that is not part of their personality ( ego dystonia ). People with social phobias are also more likely to fear the accompanying social circumstances , while fearful-avoidant people are more fearful of the intimacy and self-disclosure in close relationships. Finally, important distinguishing features of people with an anxious avoidant personality disorder are the general discomfort in most social situations, the clear fear of criticism and rejection, and pronounced shyness. In contrast to social phobia, the first signs of AEVPS show in early childhood and then develop throughout life.

There is also overlap with the characteristics of dependent personality disorder . However, in contrast to people with anxious avoidance personality disorder, the focus is on the need to be cared for . Both personality disorders can exist at the same time. Another common comorbidity is borderline personality disorder .

Emergence

Genetic factors are also being discussed more and more frequently as causes - above all a personality- typical vulnerability in the form of inner restlessness, tension, nervousness and the associated lack of responsiveness , which ultimately leads to increased vulnerability. This genetic predisposition can, in an unfavorable combination with negative psychosocial influences in everyday life, make a causal contribution to the development of the disorder. The personality traits neuroticism and introversion, which are strongly pronounced in people who avoid anxiety, are considered to be inheritable. A pathogenesis that emphasizes heredity in excess does not have a sufficient scientific basis in the form of sufficiently meaningful studies, especially in the case of anxious-avoidant personality disorder. Therefore, the possibly decisive influence of early childhood should also be considered. So far, however, there are only speculations and no reliable empirical studies.

As children, the people concerned thus find themselves in a conflict between the need for attachment and the need for autonomy . On the one hand they long for closeness and security, on the other hand they avoid close relationships. This fundamental conflict of psychosocial development is not successfully mastered. If it comes to actual rejection and devaluation by parents, friends or other related parties, these internalized can ( internalized are) and continue in self-devaluation and self-alienation. As a result, no healthy self-worth is built; Social challenges and ties are increasingly being avoided with fear or at least appearing fearful. In addition, those affected underestimate their own interpersonal skills and often have unfavorable, counterproductive and self-critical thoughts in stressful situations. Their behavior is an expression of fear and helplessness in the face of parental upbringing practices; sometimes alienation occurs later. Parents are experienced as oppressive, restrictive, low in emotion and not empathetic (see also double bond theory ).

frequency

The incidence of insecure personality disorder is around 1% - 2%. Men are just as often affected as women. In comparison, the probability of developing a social phobia in life is significantly higher and is around 11–15%. Since both diseases show similar symptoms, many sufferers get both diagnoses (in up to 46% of cases).

course

The constant prevalence of fear and tension can lead to a further decline in social skills . This enables a vicious circle so that those affected avoid potentially dangerous social situations. As a result, new experiences or alternative possibilities are hardly ever experienced. Partner relationships are rare and often fraught with conflict. Strong fear of abandonment and problems of demarcation can lead to broken relationships and thus to a confirmation of fears and repetition of negative experiences.

In contrast to many other personality disorders, such as schizoid personality disorder or antisocial personality disorder , those affected feel a high degree of subjective suffering. Since the quality of life is noticeably reduced, many are also willing to accept professional help. There is a high level of therapy compliance .

The symptoms characteristic of anxiety-avoidant personality disorder appear to be relatively stable over time. ÄVPS is a neglected clinical picture which, given its frequency and the associated stresses, requires more research.

treatment

Psychotherapeutic treatment methods are considered the method of choice for treating anxiety-avoiding personality disorders. Behavioral therapeutic approaches prove to be superior to non-specific methods. Group and individual therapeutic training of social skills is used, whereby feelings of loneliness and being left alone are more difficult to influence through social training (Cappe and Alden, 1996). Group therapy can help people with EVPS. Since the group mode makes social demands, it offers those affected a meaningful exercise field (Piper & Joyce, 2001). Dealing with biographical aspects and thought patterns are frequent therapy contents. Cognitive behavioral therapy can help improve self-insecurity, fear of negative judgment, avoidance, and depression. In a comparative study of depressed patients with AEVPS, the cognitive-behavioral approach was superior to interpersonal therapy (Barber and Muenz 1996). More recent results of a randomized controlled study on the treatment of AEVPS also showed a superiority of the cognitive-behavioral therapeutic approach compared to a waiting control group and also to the psychodynamic therapy according to Luborsky (Emmelkamp et al. 2006). The study by Alden (1989) showed that, despite clear improvements in social behavior, patients did not achieve a functional level that can be described as normal through pure group training of social skills. In the studies by Barber (1997) and Renneberg (1990), too, the participants rarely achieved the level of healthy comparators. Empirical evidence of effectiveness can also be found to a limited extent in interpersonal therapy and psychodynamic therapy .

Alternative behaviors that go in the direction of "initiative" and "risk" can be systematically reinforced within the framework of psychotherapy. For example, when a client dares to take up a conversation of his own accord, to speak to a potential partner, to reveal something or to perceive and accept positive information about himself. The person concerned should be given sufficient opportunities to recognize their own insecurities and contradictions. Various techniques such as targeted assistance, behavioral feedback , role play or video feedback can be used to strengthen self-confidence . Possible states of loneliness or depression often require further therapeutic strategies. However, they often decrease through increased (positive, supportive) social contacts. In addition to the individual therapeutic approach, therapy in groups has also proven itself.

So far, however, there is no meta-analysis on the effectiveness of psychotherapy in AEVPS. Results from meta-analyzes on the psychotherapeutic treatment of social phobia cannot be transferred 1: 1 because it can be assumed that the symptoms of AEVPS are more severe. There is also a lack of studies on differences in effectiveness for groups or individual therapy.

Symptoms such as anxiety and discomfort can be personalized with anxiolytic or antidepressant acting psychotropic drugs reduce. However, the symptoms return after discontinuation (Koenigsber et al. 2002). However, the use of psychotropic drugs to treat AVPS has not been adequately proven scientifically.

literature

  • Peter Fiedler , Sabine C. Herpertz: Personality disorders . 7th edition, Beltz Verlag, Weinheim 2016, ISBN 978-3-621-28013-6 , pp. 329–347.
  • Hans Gunia: Anxious personality disorder , in: Stephanie Amberger, Sibylle C. Roll (Ed.): Psychiatriepflege und Psychotherapie , Thieme, Stuttgart 2010, ISBN 978-3-13-148821-3 , pp. 397-398.
  • Christian Oettinger: Social phobia and insecure personality disorder. Aspects of discriminant validity , University of Heidelberg 1998. ( Diploma thesis )
  • Rainer Sachse, Jana Fasbender, Meike Sachse: Clarification-oriented psychotherapy of the insecure personality disorder, Hogrefe, Göttingen 2014, ISBN 978-3-80-172619-5
  • Rainer Sachse: Personality Disorders, Hogrefe, 3rd updated and expanded edition, Göttingen 2019, ISBN 978-3-8017-2906-6
  • Ulrich Stangier, Thomas Heidenreich, Monika Peitz: Social phobias , Beltz, Weinheim [u. a.] 2003, ISBN 3-621-27541-X .

Web links

Individual evidence

  1. ↑ WHO: ICD-10 F60.6. WHO, accessed March 5, 2020 .
  2. ↑ a b Rainer Sachse: Understanding Personality Disorders - For Dealing with Difficult Clients . Ed .: Psychiatrie Verlag. 10th edition. 2016, ISBN 978-3-88414-508-1 , pp. 85-89 .
  3. ↑ Peter Fiedler: Personality Disorders , Section 51ff ( Memento from March 23, 2014 in the Internet Archive ) (PDF; 832 kB)
  4. ↑ Uwe Henrik Peters (1999): Dictionary of Psychiatry and Medical Psychology . Bechtermünz Verlag, ISBN 978-3860478646 . See keyword Hypersensitive PS (Page 660).
  5. ↑ a b See guideline personality disorders of the AWMF guidelines personality disorder ( Memento from January 23, 2013 in the Internet Archive ) (PDF; 4 MB) pp. 10–11, 40.
  6. ↑ Peter Falkai, Hans-Ulrich Wittchen (ed.): Diagnostic and statistical manual of mental disorders DSM-5 . Hogrefe, Göttingen 2015, ISBN 978-3-8017-2599-0 , pp. 922 f .
  7. ↑ a b Rainer axis: personality disorders . 3. Edition. Hogrefe, Göttingen 2019, ISBN 978-3-8017-2906-6 , pp. 7 .
  8. ↑ a b c Peter Fiedler; Sabine C. Herpertz: Personality Disorders . 7th edition. Beltz Verlag, Weinheim 2016, ISBN 978-3-621-28013-6 , p. 334, 345, 347 .
  9. ↑ a b Peter Fiedler, Michael Marwitz (2016): Self-insecure and schizoid - variants of a disorder?
  10. ↑ Peter Fiedler, Sabine C. Herpertz: Personality disorders . 7th edition. Beltz Verlag, Weinheim 2016, ISBN 978-3-621-28013-6 , p. 335 .
  11. ↑ DL Fogelson, KH Nuechterlein u. a .: Avoidant personality disorder is a separable schizophrenia-spectrum personality disorder even when controlling for the presence of paranoid and schizotypal personality disorders. In: Schizophrenia Research. 91, 2007, p. 192, doi : 10.1016 / j.schres.2006.12.023 .
  12. ↑ W. Ecker: Personality disorders . In: M. Linden, M. Hautzinger (Ed.): Behavior Therapy . 2nd Edition. Springer, Berlin Heidelberg New York 1993, ISBN 3-540-56202-8 , pp. 384 .
  13. ↑ Peter Fiedler: Personality disorders . In: M. Zielke, J. Sturm (Ed.): Handbook of stationary behavior therapy . Belz - Psychologie Verlagsunion, 1994, ISBN 3-621-27195-3 , pp. 789-790 .
  14. ↑ A. Beck, A. Freeman: Cognitive therapy of personality disorders . 2nd Edition. Psychologie Verlags Union, Weinheim 1993, ISBN 3-621-27155-4 , p. 7 .
  15. ↑ a b c d Ronald J. Comer: Clinical Psychology . 6th edition. Spektrum, Heidelberg 2008, ISBN 978-3-8274-1905-7 , Self-insecure personality disorder, p. 438 .
  16. ↑ Peter Fiedler, Michael Marwitz (2016): Differentiation from social phobia
  17. ↑ Guidelines for Personality Disorders ( Memento from January 23, 2013 in the Internet Archive ) p. 15f.
  18. ^ William J. Magee (1996): Agoraphobia, simple phobia and social phobia in the National Comorbidity Survey. In: Archives of General Psychiatry . 53, pp. 159-168. doi : 10.1001 / archpsyc.1996.01830020077009
  19. ^ A b Anna Weinbrecht, Lars Schulze, Johanna Boettcher, Babette Renneberg: Avoidant Personality Disorder: a Current Review. In: Current Psychiatry Reports. 18, 2016, doi : 10.1007 / s11920-016-0665-6 .
  20. ↑ a b c d e Berger Mathias: Mental illnesses . Ed .: Berger Mathias. 6th edition. Urban & Fischer Verlag, Munich, ISBN 3-437-22485-9 , pp. 635 .
  21. ↑ a b Babette Renneberg, Bernt Schmitz, Stephan Doering, Sabine Herpertz, Martin Bohus: Guideline Commission on Personality Disorders: Treatment Guideline Personality Disorders . In: Psychotherapist . tape 55 . Springer, Heidelberg 2010, p. 339–354 , doi : 10.1007 / s00278-010-0748-5 ( fu-berlin.de [PDF]).
  22. ↑ D. Wedekind, B. Bandelow, E. Rüther: Pharmacotherapy for personality disorders . In: Progress in the neurology of psychiatry . tape 73 , no. 5 . Thieme, 2005, p. 259-267 , doi : 10.1055 / s-2004-830107 .