What is Experiential Avoidance?

Introduction

Experiential avoidance (EA) has been broadly defined as attempts to avoid thoughts, feelings, memories, physical sensations, and other internal experiences – even when doing so creates harm in the long run.

The process of EA is thought to be maintained through negative reinforcement – that is, short-term relief of discomfort is achieved through avoidance, thereby increasing the likelihood that the avoidance behaviour will persist. Importantly, the current conceptualisation of EA suggests that it is not negative thoughts, emotions, and sensations that are problematic, but how one responds to them that can cause difficulties. In particular, a habitual and persistent unwillingness to experience uncomfortable thoughts and feelings (and the associated avoidance and inhibition of these experiences) is thought to be linked to a wide range of problems.

Background

EA has been popularised by recent third-wave cognitive-behavioural theories such as acceptance and commitment therapy (ACT). However, the general concept has roots in many other theories of psychopathology and intervention.

Psychodynamic

Defence mechanisms were originally conceptualised as ways to avoid unpleasant affect and discomfort that resulted from conflicting motivations. These processes were thought to contribute to the expression of various types of psychopathology. Gradual removal of these defensive processes are thought to be a key aspect of treatment and eventually return to psychological health.

Process-Experiential

Process-experiential therapy merges client-centred, existential, and Gestalt approaches. Gestalt theory outlines the benefits of being fully aware of and open to one’s entire experience. One job of the psychotherapist is to “explore and become fully aware of [the patient’s] grounds for avoidance” and to “[lead] the patient back to that which he wishes to avoid”. Similar ideas are expressed by early humanistic theory:

“Whether the stimulus was the impact of a configuration of form, color, or sound in the environment on the sensory nerves, or a memory trace from the past, or a visceral sensation of fear or pleasure or disgust, the person would be ‘living’ it, would have it completely available to awareness…he is more open to his feelings of fear and discouragement and pain…he is more able fully to live the experiences of his organism rather than shutting them out of awareness.”

Behavioural

Traditional behaviour therapy utilises exposure to habituate the patient to various types of fears and anxieties, eventually resulting in a marked reduction in psychopathology. In this way, exposure can be thought of as “counter-acting” avoidance, in that it involves individuals repeatedly encountering and remaining in contact with that which causes distress and discomfort.

Cognitive

In cognitive theory, avoidance interferes with reappraisals of negative thought patterns and schema, thereby perpetuating distorted beliefs. These distorted beliefs are thought to contribute and maintain many types of psychopathology.

Third-Wave Cognitive-Behavioural

The concept of EA is explicitly described and targeted in more recent CBT modalities including acceptance and commitment therapy (ACT), dialectical behaviour therapy (DBT), functional analytic psychotherapy (FAP), and behavioural activation (BA).

Associated Problems

  • Distress is an inextricable part of life; therefore, avoidance is often only a temporary solution.
  • Avoidance reinforces the notion that discomfort, distress and anxiety are bad, or dangerous.
  • Sustaining avoidance often requires effort and energy.
  • Avoidance limits one’s focus at the expense of fully experiencing what is going on in the present.
  • Avoidance may get in the way of other important, valued aspects of life.

Empirical Evidence

  • Laboratory-based thought suppression studies suggest avoidance is paradoxical, in that concerted attempts at suppression of a particular thought often leads to an increase of that thought.
  • Studies examining emotional suppression and pain suppression suggest that avoidance is ineffective in the long-run. Conversely, expressing the unpleasant emotions can lead to improvements in the long term, even though it increases negative reactions in the short term.
  • Exposure-based therapy techniques have been shown to be effective in treating a wide range of psychiatric disorders.
  • Numerous self-report studies have linked EA and related constructs (avoidance coping, thought suppression) to psychopathology and other forms of dysfunction.

Relevance to Psychopathology

Seemingly disparate forms of pathological behaviour can be understood by their common function (i.e., attempts to avoid distress). Some examples include:

DiagnosisExample BehavioursTarget of Avoidance
Major Depressive Disorder (MDD)Isolation/SuicideFeelings of sadness, guilt, and low self-worth.
Posttraumatic Stress Disorder (PTSD)Avoiding trauma reminders and hypervigilanceMemories, anxiety, and concerns of safety.
Social PhobiaAvoiding social situationsAnxiety and concerns of judgement of others.
Panic DisorderAvoiding situations that might induce panicFear and physiological sensations.
AgoraphobiaRestricting travel outside of home or other ‘safe areas’Anxiety and fear of having symptoms of panic.
Obsessive-Compulsive DisorderChecking/RitualsWorry of consequences (e.g. ‘contamination’).
Substance Use DisordersAbusing alcohol/drugsEmotions, memories, and withdrawal symptoms.
Eating DisordersRestricting food intake and purgingWorry about becoming overweight and fear of losing control.
Borderline Personality DisorderSelf-harm (e.g. cutting)High emotional arousal.

Relevance to Quality of Life

Perhaps the most significant impact of EA is its potential to disrupt and interfere with important, valued aspects of an individual’s life. That is, EA is seen as particularly problematic when it occurs at the expense of a person’s deeply held values. Some examples include:

  • Putting off an important task because of the discomfort it evokes.
  • Not taking advantage of an important opportunity due to attempts to avoid worries of failure or disappointment.
  • Not engaging in physical activity/exercise, meaningful hobbies, or other recreational activities due to the effort they demand.
  • Avoiding social gatherings or interactions with others because of the anxiety and negative thoughts they evoke.
  • Not being a full participant in social gatherings due to attempts to regulate anxiety relating to how others are perceiving you.
  • Being unable to fully engage in meaningful conversations with others because one is scanning for signs of danger in the environment (attempting to avoid feeling “unsafe”).
  • Inability to “connect” and sustain a close relationship because of attempts to avoid feelings of vulnerability.
  • Staying in a “bad” relationship to try to avoid discomfort, guilt, and potential feelings of loneliness a break-up might entail.
  • Losing a marriage or contact with children due to an unwillingness to experience uncomfortable feelings (e.g. achieved through drug or alcohol abuse) or symptoms of withdrawal.
  • Not attending an important graduation, wedding, funeral, or other family event to try to avoid anxiety or symptoms of panic.
  • Engaging in self-destructive behaviours in an attempt to avoid feelings of boredom, emptiness, worthlessness.
  • Not functioning or taking care of basic responsibilities (e.g. personal hygiene, waking up, showing up to work, shopping for food) because of the effort they demand and/or distress they evoke.
  • Spending so much time attempting to avoid discomfort that one has little time for anyone or anything else in life.

Measurement

Self-Report

The Acceptance and Action Questionnaire (AAQ) was the first self-report measure explicitly designed to measure EA, but has since been re-conceptualised as a measure of “psychological flexibility”. The 62-item Multidimensional Experiential Avoidance Questionnaire (MEAQ) was developed to measure different aspects of EA. The Brief Experiential Avoidance Questionnaire (BEAQ) is a 15-item measure developed using MEAQ items, which has become the most widely used measure of experiential avoidance.

What is Psychological Flexibility?

Flexibility is a personality trait that describes the extent to which a person can cope with changes in circumstances and think about problems and tasks in novel, creative ways. This trait is used when stressors or unexpected events occur, requiring a person to change their stance, outlook, or commitment. Flexible personality should not be confused with cognitive flexibility, which is the ability to switch between two concepts, as well as simultaneously think about multiple concepts. Researchers of cognitive flexibility describe it as the ability to switch one’s thinking and attention between tasks. Flexibility, or psychological flexibility, as it is sometimes referred to, is the ability to adapt to situational demands, balance life demands, and commit to behaviours.

  • Refer to:
  • Opposite concepts:
    • Acceptance.
    • Distress tolerance.
    • Psychological flexibility.
  • Related concepts:
    • Denial.
    • Expressive suppression.

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What is Social Inhibition?

Introduction

Social inhibition is a conscious or subconscious avoidance of a situation or social interaction.

With a high level of social inhibition, situations are avoided because of the possibility of others disapproving of their feelings or expressions. Social inhibition is related to behaviour, appearance, social interactions, or a subject matter for discussion. Related processes that deal with social inhibition are social evaluation concerns, anxiety in social interaction, social avoidance, and withdrawal.

Also related are components such as cognitive brain patterns, anxious apprehension during social interactions, and internalising problems. It also describes those who suppress anger, restrict social behaviour, withdraw in the face of novelty, and have a long latency to interact with strangers. Individuals can also have a low level of social inhibition, but certain situations may generally cause people to be more or less inhibited. Social inhibition can sometimes be reduced by the short-term use of drugs including alcohol or benzodiazepines.

Major signs of social inhibition in children are cessation of play, long latencies to approaching the unfamiliar person, signs of fear and negative affect, and security seeking. Also in high level cases of social inhibition, other social disorders can emerge through development, such as social anxiety disorder and social phobia.

Background

Social inhibition can range from normal reactions to social situations to a pathological level, associated with psychological disorders like social anxiety or social phobia. Life events are important and are related to our well-being and inhibition levels. In a lab study conducted by Buck and colleagues, social inhibition in everyday life was reviewed. Researchers observed how individuals interacted and communicated about different stimuli. In this study, there were female participants called “senders” who viewed twelve emotionally loaded stimuli. There were also participants in the study called “received” who had to guess which stimuli was viewed by the senders. The senders were either alone, with a friend, or with a stranger while viewing the slides. The results of the study revealed that being with a stranger had inhibitory effects on communication, whereas being with a friend had facilitative effects with some stimuli and inhibitory effects with others. The results show how anyone can be inhibited in daily life, with strangers or even friends. Inhibition can also be determined by one’s sensitivity levels to different social cues throughout the day. Gable and colleagues conducted a study in which they examined different events participants would record at the end of their day. Participants were also measured on the behavioural activation system and the behavioural inhibition system. The results revealed that individuals with more sensitivity on the behavioural inhibition system reported having more negative effects from daily events.

Expression can also be inhibited or suppressed because of anxiety to social situations or simple display rules. Yarczower and Daruns’ study about social inhibition of expression defined inhibition of expression as a suppression of one’s facial behaviour in the presences of someone or a perceived anxious situation. They addressed the display rules we all learn as children; we are told what expressions are suitable for what situations. Then as age increases we are socialised into not expressing strong facial emotions. However, leaving the face with a reduced expression hinders communication. In turn this makes the face a less reliable social cue during social interactions. Friedmen and Miller-Herringer bring these nonverbal expressions to the next level by studying individuals that have a greater level of emotional suppression. They state that without proper emotional expression social interactions can be much more difficult because others may not understand another individual’s emotional state.

This being said, there are also four commonly seen irrational cognitive patterns involved in social inhibition. The first pattern centres on self-esteem and perfectionism. In these cases, an individual would inhibit themselves through self-criticism; they want to do everything the “right” way. The second pattern deals with unrealistic approval needs; here individuals want to gain the approval of others and will fear rejection if they express too much. In the third pattern, unrealistic labelling of aggressive and assertive behaviour depicts how many individuals that inhibit themselves may feel as though aggression or assertiveness is bad. They believe if they express these behaviours they will receive a negative label. The last pattern discusses criticism of others, this pattern is a spin-off from the first. They will be highly critical of others much like they are to themselves. Shyness is another factor that is a part of social inhibition. Shyness is associated with low emotional regulations and high negative emotions. In many cases shy individuals have a greater change of social inhibition.

Although social inhibition is a common part of life, individuals can also have high levels of inhibition. Social Inhibition on higher levels can sometimes be a precursor to disorders such as Social Anxiety Disorder. Essex and colleagues found that some early risk factors may play a role in having chronically high inhibition. In this study, mothers, teachers, and the child reported on the child’s behavioural inhibition. The factors that were found to be contributors to social inhibition were female gender, exposure to maternal stress during infancy and the preschool period, and early manifestation of behavioural inhibition. In severe cases, clinical treatment, such as therapy, may be necessary to help with social inhibition or the manifesting social disorder.

Over the Lifespan

Social inhibition can develop over a lifespan. Children can be withdrawn, adolescents can have anxiety to social situations, and adults may have a hard time adjusting to social situations which they have to initiate on their own. To be inhibited can change and be different for many. In many cases, inhibition can lead to other social disorders and phobias.

Infants and Children

In infants and children, social inhibition is characterised by a temperament style that will have children responding negatively and withdrawing from unfamiliar people, situations and objects. In addition to cessation of play, inhibited children may display long latencies to approaching an unfamiliar person, signs of fear and negative affect, and security seeking. Avoiding behaviour can be seen at a very young age. In one study, Fox and colleagues found that even at four months of age some infants had negative responses to unfamiliar visual and audio stimuli. The study was longitudinal; therefore, follow ups revealed that half the infants who had high negative responses continued to show behavioural inhibition through the age of two. Fox’s longitudinal study reported that the expression of behavioural inhibition showed a small degree of continuity. Over time, the toddlers who were quiet and restrained continued the trend into childhood by being cautious, quiet, and socially withdrawn. The uninhibited control group of the same ages continued to interact easily with unfamiliar people and situations. There has also been a link between inhibition at childhood age with social disorders in adolescents and adulthood. Schwartz and Kagan found that in a longitudinal study from ages two to thirteen, sixty-one percent of teens who had inhibitor traits as toddlers reported social anxiety symptoms as adolescents, compared to twenty-seven percent of adolescents who were uninhibited in earlier life. However, not every child that has some withdrawn or inhibited behaviour will be inhibited as an adolescent or manifest a social disorder.

The caregiver alone is not solely responsible for inhibition in children; however, in some cases it can be a factor. Caregivers can affect the inhibition levels of their child by exposing the child to maternal stress during infancy and the preschool period. In addition, in some situations the child may simply have early manifestation of behavioural inhibition. There seems to be no parenting style that researchers agree on to be the best to combat social inhibition. Park and Crinic say that a sensitive, accepting, overprotective parenting is best to reduce the negative behaviours because it will allow the child to be themselves without judgement. However, Kagan hypothesized that firm parenting styles are better suited for socially inhibited children. Researchers supporting sensitive parenting believe that too firm of a parenting style will send a message to children that says they need to change.

Adolescence

Social inhibition has been widely studied in children; however, research on how it develops through adolescence and adulthood is not as prevalent, although anxiety-related social problems are most commonly seen in adolescents. Many of the behavioural traits are the same in adolescence as they are in childhood: withdrawing from unfamiliar people, situations and objects. However, it has been tested that adolescents are more aware of their social situations and are more likely to be inhibited in public settings. Researchers found younger individuals to be more likely to differentiate between public and private settings when inquiring about potentially embarrassing issues. It is also thought that inhibition is in many ways addressed in childhood and adolescence simply because schools facilitate interactions with others. As an adult, the same facilitating circumstance may not occur unless the individual prompts them on their own. Gest states that adults do not have as many casual peer interactions and friendship opportunities that guide and support relationships unless they facilitate them on their own. Adolescent research has also shown that social inhibition is associated with a more negative emotional state in young men than women.

This is in contrast to a study that measured inhibition levels through self reports from the adolescent and their parents. West and Newman found that young American Indian women and their parents reported higher levels of inhibition than young American Indian men; in addition, the parental reports also predicted social anxiety in young American Indian women over young American Indian men. In this same study, relationship development with peers was investigated over time. West and Newman stated that low levels of behavioural inhibition had an association with early social and school situations and that were related to greater levels of socially mediated anxiety, especially negative evaluation of fear by peers. This study then speculates about the possibility that adolescents and children who have a generally positive social experience will be more aware of the status of these positive relationships, therefore more anxious about failure in their social domain. Other studies also discussed how in many cases, early behavioural inhibition is a risk factor for the development of chronic high school-age inhibition and possible social anxiety disorder. Although social inhibition can be a predictor of other social disorders there is not an extremely large portion of adolescents who have developed an anxiety disorder and also had a history of inhibition in childhood.

Besic and Kerr believes that appearance can be a factor for social inhibition. In their study they hypothesized that a way to handle difficult situations with behavioural inhibition was to present an off-putting appearance. They examined “radical” crowds, such as those labelled as goths and punks and if their appearances fulfilled a functions for their inhibition. They state that a radical style could be used to draw away the social boundaries and relieve them of pressures or expectations to interact in unfamiliar situations with unfamiliar peers. Another possibility is that an individual may be self-handicapping to ensure that they will not have to interact with unfamiliar peers. The results revealed that radicals were significantly more inhibited than other groups. However, there are other inhibited individuals in other social classifications. The highest inhibited radical was no more inhibited than the highest inhibited individual in other groups.

Adulthood

Adult cases of social inhibition are hard to come by simply because many see it as something that happens through development. Although research is lacking, developmental considerations suggest there may be a stronger association between behavioral inhibition and peer relations in adulthood. One researcher says this lack of information may be because adults are not put in as many socially interactive situations that would guide them through the situation. It would seem that adults have an increased responsibility to initiate or structure their own social peer relationships; this is where social inhibition could have a more problematic role in adulthood than in childhood. One study that did contribute to adult research used questionnaires to study both clinical and nonclinical adults. Like in adolescence, behavioral inhibition was also found to be associated with anxiety disorders in adulthood. In addition the study found that childhood inhibition was specifically a factor in a lifetime diagnosis of social phobia. Gest also measured adult peer relations, and to what degree they had a positive and active social life. For example, researchers wanted to know if they participated in any recreational activities with others, how often they met with others, and if they had any close confiding relationships. The participants were rated on a 5-point scale on each peer relationship they disclosed. The results revealed that social inhibition had nothing to do with popularity, however it was correlated with peer relations in both genders and emotional stress in only men.

A similar study found that some shy men had a low occupational status at age forty because they entered their career later in life. However, another researcher has commented on this giving this example, perhaps remaining at home longer allows young adults to accumulate educational and financial resources, before moving out and becoming more independent. Additionally it was found that young adults who were inhibited as children were less likely to move away from their families. There is also some discussion of the inhibition through generations and children mirroring their parents. Results indicated that children whose birth mothers met criteria for the diagnosis of social phobia showed elevated levels of observed behavioural inhibition. Social inhibition can decrease with age due to cognitive deficits that can occur in old age. Age-related deficits have an effect on older adults’ ability to differentiate between public and private settings when discussing potentially embarrassing issues, leading them to discuss personal issues in inappropriately public situations. This suggests that deficits in inhibitory ability that lead to inappropriateness are out of the individual’s control.

In Different Contexts

In Schools

Schools can be a place for children to facilitate different social interactions; however, it can also uncover social and school adjustment problems. Coplan claims that Western children with inhibition problems may be at a higher risk of developmental problems in school. Although social inhibition may be a predictor of social and school adjustment problems in children, Chen argues that the effect of social inhibition on school adjustment differs between Western cultures and Chinese culture. Chen found that in Chinese children, behavioural inhibition was associated with greater peer liking, social interaction, positive school attitudes, and school competence and fewer later learning problems, which is also different from western cultures. In other studies, researchers such as Oysterman found there to be difficulties in adjustment in children that were experiencing inhibition. In Western cultures, these difficulties are seen more because of the emphasis on social assertiveness and self-expression as traits that are valued in development. In other cultures children are sometimes expected to be inhibited. This does not contrast with other cultures in which children are socialised and assert themselves. Despite these differences there are also similarities between gender. Boys were more antagonistic in peer interaction and seemed to have more learning problems in school. Girls were more cooperative in peer interaction and had a more positive outlook on school. They formed more affiliations with peers, and performed more completely in school.

Other researchers like Geng have looked to understand social inhibition, effortful control, and attention in school. In Geng’s study, gender came in to play with high socially inhibited girls being extremely aware of their surroundings, possibly paying too much attention to potentially anxious situations. It is well known in a large number of research studies social inhibition had been linked to other anxiety disorders. However Degnan and colleagues believe that being able to regulate your effortful control may serve to reduce the anxiety the comes from inhibition. Nesdale and Dalton investigated inhibition of social group norms in school children between the ages of seven and nine. In schools there becomes an increase in social in-groups and out-groups as children increase in age. This study created different in-groups or exclusive groups and out-groups or inclusive groups. The results showed that students in the inclusive group liked all students more, while students in the exclusive group like their group over other groups. This study could help in the future to facilitate school peer groups more efficiently.

In the Workplace

Social inhibition can manifest in all social situations and relationships. One place that we can see the effects of social inhibition is in the workplace. Research has shown that social inhibition can actually affect the way that one completes a given amount of work. In one experiment, participants completed a task in a laboratory setting, varying whether or not another individual was present in the room with the participants while they attempted to complete the task. The results showed that when another individual was present in the room the person focused on completing the experimental task decreased their body movements, hand movements, and vocalisation, even though the other person did not speak to or even look at the participant. This suggests that just the mere presence of another person in a social situation can inhibit an individual. However, although the individual in charge of completing the experimental task was socially inhibited by the presence of another person in the laboratory, there were no significant links between their social inhibition when completing the task and improved performance on said task. These findings suggest that an individual may socially inhibit themselves in the work place if another person is also in the room, however, such inhibition does not suggest that the inhibited individual is actually performing the duties assigned to them with more accuracy or focus.

In Psychological Disorders

Depression

Links between social inhibition and depression can be found in individuals who experienced social inhibited behaviours during childhood. Researchers from the UK conducted a study in an attempt to explain possible links between social inhibition in infancy and later signs of depression. The researchers based their study on previous information from literature acknowledging that there are social and non-social forms of inhibition, and that social inhibition is significantly related to early social fears. The researchers hypothesized that social inhibition in childhood would be linked to higher levels of depression in later years. Participants completed a number of questionnaires about their experiences of social inhibition in childhood and their current levels of depression. Results showed a significant relationship between depression and recalled social fears, or, social inhibitions during childhood. Furthermore, the researchers related their findings to another study conducted by Muris et al., in 2001 which found that there is an association between social inhibition and depression in adolescents. The study compared adolescents who were not inhibited to those who are, and found that:

“adolescents experiencing high levels of behavioral inhibition were more depressed than their counterparts who experienced intermediate or low levels of behavioral inhibition”.

Another study set out to examine the link between social inhibition and depression, with the basis for their study being that social inhibition (which they explain as a part of type D personality, or distressed personality) is related to emotional distress. The researchers explain that a major factor related to social inhibition is the inhibited individual not expressing their emotions and feelings, a factor that the researchers cite in relation to the link between social inhibition and depression. Overall, the results of the study show that social inhibition (as a factor of type D personality) predicts depression, regardless of the baseline depression level of the individual. Significantly, this study was conducted with young, healthy adults, as opposed to working with those in self-help groups or with individuals who have a pre-existing medical or psychological condition.

Fear

Social inhibition can be affected by fear responses that one has in the early “toddler years” of their life. In 2011, researchers Elizabeth J. Kiel and Kristin A. Buss examined “how attention toward an angry-looking gorilla mask in a room with alternative opportunities for play in 24-month-old toddlers predicted social inhibition when children entered kindergarten”. In the study, the researchers specifically looked at the toddlers’ attention to threat and their fear of novelty in other situations. The researchers paid special attention to these two factors due to previous research suggesting that “sustained attention to putatively threatening novelty relates to anxious behavior in the first 2 years of life”. Also, it has been found in earlier research conducted by Buss and colleagues that no matter the differences, individual responses to novelty during early childhood can be related to later social inhibition. These results already link fear responses, particularly in children, to social inhibition, mainly such inhibition that manifests later on in the individual’s life. Overall, the researchers based their experiment on the notion that the more time a toddler spends being attentive towards a novel potential threat the greater the chance that they will experience issues with the regulation of distress, which can predict anxious behaviour such as social inhibition.

Through a study intended to further connect and understand links between fear and late social inhibitions, the researchers conducted a study where they worked with 24-month-old toddlers. They placed the toddlers in a room called the “risk room” which is set up with a number of play areas for the toddlers to interact with, with one of those areas being a potentially threatening stimulus, in this case, an angry looking gorilla mask. The children are left alone, with only their primary caregiver sitting in the corner of the room, to explore the play areas for three minutes, and then the experimenter returns and instructs the toddler to interact with each of the play areas. The purpose of this was to allow for other experimenters to code the reactions of the toddler to the stimuli around him or her, paying special attention to their attention to threat, their proximity to the threat, and their fear of novelty.

The results of this study indicate that attention to threat (attention given, by the toddler to the feared stimuli) predicts social inhibition in kindergarten. Further, if the child approaches the feared stimuli, the relation to later social inhibition is not significant. When a child’s behaviour is to keep more than two feet away from the threatening stimulus, their behaviour can be seen as linked to later social inhibition. Another important factor that the researchers found when looking at the prediction of social inhibition is the child paying a significant amount of attention to a feared or threatening stimuli in the presence of other, enjoyable activities. Mainly, if the child’s duration of attention to the threatening stimuli is significant even when there are other enjoyable activities available for them to interact with, the link to later social inhibition is stronger due to the fact that “toddler-aged children have increased motoric skill and independence in exploring their environments; so they are capable of using more sophisticated distraction techniques, such as involvement with other activities”.

In another study looking at social inhibition and fear, the researchers made the distinction between different forms of inhibition. Mainly looking at behavioural inhibition the researchers separated the category into two subcategories, social behavioural inhibition and non-social behavioural inhibition. The researchers cite an experiment conducted by Majdandzic and Van den Boom where they used a laboratory setting to attempt to elicit fear in the children. They did this by using both social and non-social stimuli. What Majdandizic and Van der Boom found was a variability in the way that fear was elicited in the children when using either the social or non-social stimuli. Essentially, this study realised that there is a correlation between social stimuli producing fear expressions in children, whereas non-social stimuli is not correlated to fear. This can be evidence of social inhibition due to the social stimuli that result in fear expressions in children.

The researchers of the current study took the results from the Majdandizic and Van der Boom study and expanded on their work by looking at variability in fear expressions in both socially inhibited children and non-socially inhibited children. What they found was that mainly socially inhibited children have effects such as shyness and inhibition with peers, adults, and in performance situations, as well as social phobia and separation anxiety. The stronger link with fear reactions comes mainly from those children who were non-socially behaviourally inhibited. While these results go against previous findings, what the researchers were eager to stipulate was that “the normative development of fear in children have indicated that many specific fears (e.g. fear of animals) decline with age, whereas social fears increase as children get older”.

Social Phobia

Social inhibition is linked to social phobia, in so much as social inhibition during childhood can be seen as a contributing factor to developing social phobia later on in life. While social inhibition is also linked to social anxiety, it is important to point out the difference between social anxiety and social phobia. Social anxiety is marked by a tendency to have high anxiety before a social interaction, but not experience the avoidance of the social activity that is associated with social phobia. Social phobia and social inhibition are linked in a few different ways, one being physiologically. When one is experiencing extreme levels of inhibition they can suffer from symptoms such as accelerated heart rate, increased morning salivary cortisol levels, and muscle tension in their vocal cords. These symptoms are also reported by those with social phobia, which indicates that both social inhibition and social phobia interact with the sympathetic nervous system when the individual encounters a stressful situation.

Further, it is suggested throughout literature that social inhibition during childhood is linked to later social phobia. Beyond that research has indicated that continuity in inhibition plays an important role in the later development of social phobia. Continuity of social inhibition means someone experiencing social inhibition for a number of year continuously. The research explains work done with young teenagers, which found that the teenagers who had been classified as inhibited 12 years earlier were significantly more likely to develop social phobia than young teenagers who were not classified as inhibited. This research pertains to the link between social inhibition and generalised social phobia, rather than specific phobias. When looking at continuity in social inhibition some research offers reasoning as to why the social inhibition may continue long enough to be a predictor of social phobia. Researchers have suggested that if the early childhood relationships are not satisfactory they can influence the child to respond to situations in certain inhibitory ways. When this happens it is often then associated with poor self-evaluation for the child, which can lead to increased social inhibition and social phobia. Also, if a child is neglected or rejected by their peers, rather than by their caregiver, they often develop a sense of social failure, which often extends into social inhibition, and later social phobia. The link between social inhibition and social phobia is somewhat exclusive, when testing for a possible link between non-social inhibition and social phobia no predictive elements were found. It is particularly social inhibition that is linked to social phobia.

The research also suggests that social inhibitions can be divided between different kinds of social fears, or different patterns of inhibition can be seen in individuals. The researchers suggest that certain patterns, or certain social fears, can be better predictors of social phobia than others. Mainly, the researchers suggest that there can be different patterns of social inhibition in relation to an unfamiliar object or encounter. These specific patterns should be looked at in conjunction with motivation and the psychophysiological reaction to the object or encounter to determine the specific patterns that are the better predictors of social phobia.

Another study aimed to examine the link between social inhibition and social phobia also found that social phobia is linked to the social phobic being able to recall their own encounters with social inhibition during childhood. The social phobic participants were able to recall social and school fears from their childhood, but they also were able to recall sensory-processing sensitivity which indicates that the social phobic participants in the study were able to recall having increased sensitivity to the situations and behaviours around them.

Another study explains that social phobia itself has a few different ways it can manifest. The study aims at understanding the link between social inhibition and social phobia, as well as depression in social phobia. What the study found was an important link connecting the severity of social inhibition during childhood to the severity of social phobia and factors of social phobia in later years. Severe social inhibition during childhood can be related to lifetime social phobia. Further, the researchers point out that inhibition during childhood is significantly linked to avoidant personality disorder in social phobia as well as childhood inhibition linked with major depressive disorder in social phobia that spans across the individual’s lifetime. A major suggestion related to the results of the study suggested that while inhibition can be a general predictor of risk factors related to social phobia, it may not be a specific predictor of social phobia alone

Social Anxiety Disorder

Social anxiety disorder is characterised by a fear of scrutiny or disapproval from others. Individuals believe this negative reaction will bring about rejections. Individuals with social anxiety disorder have stronger anxious feeling over a long period of time and are more anxious more often. In many cases, researchers have found that social inhibition can be a factor in developing other disorders such as social anxiety disorder. Being inhibited does not mean that an individual will develop another disorder; however, Clauss and colleagues conducted a study to measure the association between behavioural inhibition and social anxiety disorder. The results of the study discovered that 15% of all children have behavioural inhibition and about half of those children will eventually develop social anxiety disorder. This is why behavioural inhibition is seen as a larger risk factor.

That being said, Lim and colleagues researched the differences between early and late onset of social anxiety disorder and its relation to social inhibition. Through the duration of their study, they found those diagnosed as early onset had complaints other than ones about social anxiety symptoms. Early onset individuals would frequently have more severe symptoms and higher levels of behavioural inhibition. Additional behavioural inhibition was more severe especially in social and school situations with only the early onset cases. Lorian and Grisham researched the relationship between behavioural inhibition, risk-avoidance, and social anxiety symptoms. They found that all three factors correlated with each other and risk avoidance is potentially a mechanism linked to an anxiety pathology.

Reduction

Alcohol Consumption

Social inhibition can be lowered by a few different factors, one of them being alcohol. Alcohol consumption can be seen to lower inhibitions in both men and women. Social inhibitions generally act to control or affect the way that one conducts themselves in a social setting. By lowering inhibitions alcohol can work to increase social behaviours either negatively or positively. Importantly, one must remember that the higher the dosage of alcohol, the greater the damage it will cause to inhibitory control.

By lowering inhibitions, alcohol can cause social behaviours such as aggression, self disclosure, and violent acts. Researchers have suggested that situational cues used to inhibit social behaviours are not perceived the same way after someone consumes enough alcohol to qualify them as drunk:

“interacting parties who are impaired by alcohol are less likely to see justifications for the other’s behavior, are thus more likely to interpret the behavior as arbitrary and provocative, and then, having less access to inhibiting cues and behavioral standards, are more likely to react extremely.”

This idea of increased extreme social behaviours is believed to come as a result of lowered inhibitions after consuming alcohol. Alcohol can lower inhibitions for a number of reasons, it can reduce one’s self-awareness, impair perceptual and cognitive functioning, allows for instigator pressures to have more influence over an individual, and can reduce one’s ability to read inhibitory social cues and standards of conduct.

When attempting to examine the effects that alcohol consumption has on social inhibition researchers found that after being provoked sober individuals used inhibiting cues, such as the innocence of the instigator and the severity of the retaliation to control their response to the aggressive provocation. However, the researchers found that an intoxicated individual did not have these same inhibitions and, as a result, exhibited more extreme behaviours of retaliated aggression to the provocation without processing information they would normally consider about the situation. On average, drunken individuals exhibited more aggression, self-disclosure, risk taking behaviours, and laughter than sober individuals. Extreme behaviours are not as common in sober individuals because they are able to read inhibitory cues and social conduct norms that drunken individuals are not as inclined to consider. These negative social behaviours, then, are a result of lowered social inhibitions.

Alcohol consumption also has the ability to lower inhibitions in a positive way. Research has been conducted looking at the way an intoxicated person is more inclined to be helpful. Researchers were of the same opinion that alcohol lowers inhibitions and allows for more extreme behaviours, however, they tested to see if this would be true for more socially acceptable situations, such as helping another person. The researchers acknowledged that, generally, an impulse to help another is initiated but then inhibitions will cause the potential helper to consider all factors going into their decision to help or not to help such as, lost time, boredom, fatigue, monetary costs, and possibility of personal harm. The researchers suggest that while one may be inhibited and therefore less likely to offer help when completely sober, after consuming alcohol enough damage will be done to their inhibitory functioning to actually increase helping. While this suggestion differs from socially negative behaviours that are seen after social inhibitions have been lowered, it is consistent with the idea that alcohol consumption can lower inhibitions and, as a result, produce more socially extreme behaviours when compared to a sober counterpart.

Alcohol consumption can lower social inhibitions in both men and women, producing social behaviours not typical in the individuals’ day-to-day sober lives. For example, in social settings women will tend to be uncomfortable with sexual acts and provocations as well as feeling uncomfortable in social settings that are generally male dominated such as strip clubs or bars. However, consumption of alcohol has been seen to lower these inhibitions, making women feel freer and more ready to participate socially in events and behaviours that they would normally feel inhibited from participating in if they were sober. As an example, women participating in bachelorette parties generally consume copious amounts of alcohol for the event. As a result, the females feel less inhibited and are more likely to then engage in behaviour that they would normally view as deviant or inappropriate. In an examination of bachelorette parties it was found that when those attending the party consumed only a couple of drinks behaviour minimally reflected any alcohol consumption, assuming that the party guests were still socially inhibited and less inclined to perform deviant behaviours. Similarly, “levels of intoxication were correlated with the atmosphere of the party, such that parties with little or no alcohol were perceived as less ‘wild’ than parties a lot of alcohol consumption.” Conceivably, the bachelorette parties show tendencies of “wild” behaviour after excessive alcohol consumption, which consequently lowers the inhibitions of the consumers.

When surveyed a number of women who had attended a bachelorette party, or had one in their honour, in the past year reported that their behaviour when under the influence of alcohol was different from their behaviour when sober. One party guest reported:

“People drink … to lose inhibitions and stuff that is done… I would never do sober. It lowers inhibitions – that is the main point of it.”

These reports suggest that “alcohol was used to lower inhibitions about being too sexual, about the risk of being perceived as promiscuous, or about being sexual in public. Women commented that they felt freer to talk about sex while under the influence of alcohol, to flirt with male strangers, or to dance with a male stripper.” The research collected surrounding women and their alcohol consumption in these settings provide examples of the reduction of social inhibitions in relation to excess alcohol consumption

Power

Social inhibitions can also be reduced by means unrelated to an actual substance. Another way that social inhibition can be decreased is by the attainment of power. Research has examined the way that having either elevated or reduced power affects social interactions and well-being in social situations. Such research has shown a relationship between elevated power and decreased social inhibitions. This relationship of those with elevated power and those with reduced power can be seen in all forms of social interactions, and is marked by elevated power individuals often having access to resources that the reduced power individuals do not have. Decreased social inhibition is seen in those with elevated power for two main reasons, one being that they have more access to resources, providing them with comforts and stability. The second reason is that their status as a high power individual often provides the powerful individual a sense of being above social consequences, allowing them to act in ways that a reduced power individual may not.

The elevated power individuals will experience reduced social inhibition in various ways, one being that they are more likely to approach, rather than avoid, another person. Also, with the reduced inhibition associated with high power individuals, they are more likely to initiate physical contact with another person, enter into their personal space, and they are more likely to indicate interest in intimacy. High power people tend to be socially disinhibited when it comes to sexual behaviour and sexual concepts. Consistent with this expectation, a study working with male and female participants found that when the male and female felt equally powerful they tended to interact socially with one another in a disinhibited manner.

Further, the research suggests that as a result of their reduced social inhibition, powerful individuals will be guided to behave in a way that fits with their personality traits in a social situation in which they feel powerful. Similarly, in a laboratory study it was found that when one person in a group feels powerful their reduced social inhibition can result in decreased manners. The study found that, when offered food, the powerful individual is more likely to take more than the other individuals in the room. This can be seen as the powerful individual exhibiting reduced social inhibitions, as they reduce their attention to common social niceties such as manners and sharing.

Increase

Power

Certain factors can increase social inhibition in individuals. Increased inhibitions can occur in different situations and for different reasons. One major factor that contributes to the increase of social inhibition is power. Reduced power is linked to an array of negative affect, one of which being increased social inhibitions. Power, in this instance, can be defined as a fundamental factor in social relationships that is central to interactions, influencing behaviour and emotional display. Further, power is such an essential factor in social relationships because power determines who is the giver and who is the receiver in the exchange of rewards and resources. Power is present in all social relationships, not just typical hierarchical establishments such as in employment or school settings. Power, then, is related to increased social inhibitions when an individual feels that they are in a powerless or diminished power position. Those who are deemed to be high in power are generally richer in resources and freedom, as well as decreased levels of social inhibition, whereas those who are deemed to be low in power are generally low in resources, constrained, and prone to experiencing increased social inhibition.

Research shows that individuals who are considered to be low in power experience more social threats and punishments, and generally have less access to social resources. As a result of this these individuals are prone to developing more sensitivity to criticism from others, and are more susceptible to accepting when someone constrains them. These factors contribute to increasing social inhibition in those individuals. Similarly, studies have shown that the absence of power can heighten the processes associated with social inhibition. Experiments on the interaction between power and inhibition have shown that when participants are in a situation where they perceive more punishments and threats their cognition and behaviour will show more signs of social inhibition related affect. Environments which distinguish the differences between the powerful and the powerless can lead to the social inhibition of the power reduced individuals as a response to their social interactions with the heightened power individuals.

Some of the social inhibited behaviours that a low-power individual will experience in these social situations will be embarrassment and fear and they may even go on to feel guilt, sadness, and shame. Further, low power individuals can be seen socially inhibiting themselves in ways that can, in the end, favour the high-power individuals. These can include inhibiting themselves from providing input on ideas, hesitating in normal speech, and even increasing their facial muscle actions in order to keep themselves from displaying emotions. When the low-power individuals are in a social situation with a high-power individual they will also commonly exhibit social inhibition by inhibiting their postural constriction and reducing their gestures. Researchers have generalised these suggestions of interaction between a high-power individual and low-power individuals to say that these expressions of social inhibition are expected to carry over into all areas of social interaction for the low-power individual. That is to say that low-power individuals will not only exhibit social inhibition when in the presence of a high-power individual. They will continue to be socially inhibited in all social aspects of their lives as a result of their low-power status. Further, low-power individuals tend to devote increased attention to the actions and behaviours of others.

Biological Factors

Another possible explanation for increased social inhibition has to do with biological factors. A study of brain activity in those who rate high on the scale for social inhibition showed a number of brain areas that are related to the heightened inhibitions. In their study the researchers aimed to find the link between socially inhibited individuals and an over activation of the cortical social brain network. The researchers did this by examining the brain activity of individuals who rate high in social inhibition as they respond to video clips of facial and bodily expressions that were potentially threatening. What the researchers found was that those who rate high in social inhibition show an overactive orbitofrontal cortex, left temporo-parietal junction, and right extrastriate body area. When the threat -related activity was being presented to the participants, these areas of the brain showed increased activity in comparison to those who do not rate high for social inhibition. What the researchers speculate is that, in this instance, hyperactivity in these brain structures does not mean better functioning. Further, “the orbitofrontal cortex is connected with areas that underlie emotional function and empathy”. This relates to one’s ability to stimulate how another person feels in their own facial displays. The over activity and decreased function of these brain structures can affect individuals by increasing social inhibition and behaviours related to social inhibition.

Personality Traits

Further, there is speculation that social inhibition can also be increased by the type of personality an individual has and behaviours that those individuals inherently display. Namely, those who are dependent and reassurance seeking are more commonly likely to display increased social inhibition.

Clinical Levels

Although social inhibition can occur as part of ordinary social situations, a chronically high level of social inhibition may lead some individuals to develop other social or anxiety disorders that would also need to be handled clinically. Through childhood, adolescence, and adulthood, clinical levels of social inhibition can be measured. Social inhibition can be a precursors for other social disorders that can develop in adolescence or adulthood

Measures

There are many implications for the diagnoses of social inhibition, however there are many cost-efficient ways to measure and treat this social disorder. One measure that has reliably assessed the traits of social inhibition is the seven-item inhibition scale of the Type D Scale-14. Another measure is the Behavioural Inhibition Observation System (BIOS). In clinical trials this measure is to be used for children completed by parents, teachers, and clinicians. Other scales are the:

  • Behavioural Inhibition Questionnaire (BIQ);
  • Behavioural Inhibition Instrument (BII);
  • Behavioural Inhibition Scale (BIS);
  • Preschool Behavioural Inhibition Scale (P-BIS); and
  • Behavioural Inhibition Scale for children ages 3-6.

There are also many versions of these scales that are specifically for parents, teachers, or even the child or possibly an inhibited individual to take. There are also times when these measures are grouped together; in many cases the Behavioural Inhibition System scale and Behavioural Activation System scale are used together. These two measure are the most widely used and together they consist of behavioural inhibition and behavioural activation scales that deal with reward response and fun seeking. The Behavioural Paradigm System is an observation system that allows measurements of behavioural inhibition in systematic natural environments. With this system researchers will observe cessation of play and vocalisation, long latencies to approaching the unfamiliar person, signs of fear and negative affect, and security seeking in environments such as classrooms, playgrounds, and in home settings. This paradigm was followed by many adaptations, one specifically was the adaptation of the Observational Paradigm. In an additional study by Ballespi and colleagues the paradigm was changed to be more suitable for a school environment. The adapted paradigm met three important criteria, the tests were suitable for a school environment, there had to be materials for the test that could be transported easily, and the observation of behavioural inhibition signs had to have the potential to be seen in a short period of time.

Ballespi and colleagues discussed one of the most recent measurement systems in the Behavioural Inhibition Observation System. This new system will allow clinicians to provide a quick measure for behavioural inhibition. This system is used during the first meeting with the child. In this first meeting, the child will be exposed to a strange, unfamiliar situation. The scale will then be completed after the therapist has time to observe the child in an interview setting. Researchers want to find a way to have an actual measure for inhibition, however this is difficult. There is a difference in observations, a parent or teachers is going to observe the child over long periods of time in several natural situations. The parents do not actually observe the child but instead rate the behaviour inhibition on the ideas they have formed about the child. The clinician will not have all this information and will base his or her first measure on observation alone; they measure state while parents and teachers measure traits. This is where the differences come up in measure however after several visits the measures of the clinicians, teachers, and parents become more similar.

Treatments

Treatments used for social inhibition are primarily assertive trainings introduced by therapies. These treatments are about teaching the inhibited individual to express and assert their feeling instead of inhibiting them. Assertiveness training is an important operation for behavioural therapist because it can help with behavioural issues, as well as interpersonal inadequacies, and anxiety in adults. In some cases this training can go by a different name because assertiveness is sometimes categorised by aggression therefore it can also be called appropriate expression training.

In one study discussing assertive training Ludwig and Lazarus found irrational cognitive patterns that inhibited individuals have to deal with and how to overcome them. The four patterns are self-criticism/Perfectionism, unrealistic approval needs, unrealistic labelling of aggression/assertive behaviour, and criticism of others. There are three different phases that work to combat the irrational cognitive patterns and inhibitory actions during social situations. These phases are meant to be actively practiced. The individual will receive homework assignments, and have to do role-playing exercises to overcome their inhibitions. The first phase discussed was about talking more. Ludwig states that there cannot just be an increase in talking but also an increase in expressing and talking about how one feels. The point of this phase is to get an individual talking no matter how ridiculous or trivial it may seem. Phase two is about dealing with the responses that come from talking more. When an inhibited individual starts talking more they may become embarrassed. However, with positive reactions from others they will learn that being embarrassed about some of the comments made is not devastating, and in turn the individual may talk and act more freely. In addition to the positive feedback the individual will review particularly embarrassing moment to assess why they were embarrassed to help combat those thoughts. If the inhibited person can understand the irrational thoughts they will eventually feel less embarrassed and act more freely. Role playing is also a way to help the individual understand different social behaviours. Mirroring is a way some therapist will show the client their own behaviour. The last phase deals with additional strategies that can help through social situation such as expressing disagreement, dealing with interruptions, initiating more conversations topics, and more self-disclosure. Ludwig and colleagues also make sure to explain that no one should compulsively apply these behavioural techniques in all situations. An individual should not go over board using them; additionally there are times when initiating some conversation topics and talking more are inappropriate.

Group therapies are also used in the treatment using assertiveness. Hedquist and Weinhold investigated two group counselling strategies with socially anxious and unassertive college students. The first strategy is a behavioural rehearsal group, which aims to assist members to learn more efficient responses in social situations. This was to be accomplished by rehearsing several difficult social situations. The second strategy was a social learning group that was about honesty about everything; any withholding behaviours were seen as being dishonest. Another rule was every individual had to take responsibility for everything that said. The results of this study showed that both strategies helped significantly in treating the anxiety and unassertiveness.

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What is Avoidant Personality Disorder?

Introduction

Avoidant personality disorder (AvPD) is a Cluster C personality disorder in which the main coping mechanism of those affected is avoidance of feared stimuli.

Those affected display a pattern of severe social anxiety, social inhibition, feelings of inadequacy and inferiority, extreme sensitivity to negative evaluation and rejection, and avoidance of social interaction despite a strong desire for intimacy.

People with AvPD often consider themselves to be socially inept or personally unappealing and avoid social interaction for fear of being ridiculed, humiliated, rejected, or disliked. They often avoid becoming involved with others unless they are certain they will be liked.

Childhood emotional neglect (in particular, the rejection of a child by one or both parents) and peer group rejection are associated with an increased risk for its development; however, it is possible for AvPD to occur without any notable history of abuse or neglect.

Brief History

The avoidant personality has been described in several sources as far back as the early 1900s, although it was not so named for some time. Swiss psychiatrist Eugen Bleuler described patients who exhibited signs of avoidant personality disorder in his 1911 work Dementia Praecox: Or the Group of Schizophrenias. Avoidant and schizoid patterns were frequently confused or referred to synonymously until Kretschmer (1921), in providing the first relatively complete description, developed a distinction.

Signs and Symptoms

Avoidant individuals are preoccupied with their own shortcomings and form relationships with others only if they believe they will not be rejected. They often view themselves with contempt, while showing a decreased ability to identify traits within themselves that are generally considered as positive within their societies. Loss and social rejection are so painful that these individuals will choose to be alone rather than risk trying to connect with others.

Some with this disorder fantasize about idealized, accepting and affectionate relationships because of their desire to belong. They often feel themselves unworthy of the relationships they desire, and shame themselves from ever attempting to begin them. If they do manage to form relationships, it is also common for them to pre-emptively abandon them out of fear of the relationship failing.

Individuals with the disorder tend to describe themselves as uneasy, anxious, lonely, unwanted and isolated from others. They often choose jobs of isolation in which they do not have to interact with others regularly. Avoidant individuals also avoid performing activities in public spaces for fear of embarrassing themselves in front of others.

Symptoms include:

  • Extreme shyness or anxiety in social situations, though the person feels a strong desire for close relationships;
  • Heightened attachment-related anxiety, which may include a fear of abandonment; and
  • Substance abuse and/or dependence.

Comorbidity

AvPD is reported to be especially prevalent in people with anxiety disorders, although estimates of comorbidity vary widely due to differences in (among others) diagnostic instruments. Research suggests that approximately 10-50% of people who have panic disorder with agoraphobia have avoidant personality disorder, as well as about 20-40% of people who have social anxiety disorder. In addition to this, AvPD is more prevalent in people who have comorbid social anxiety disorder and generalised anxiety disorder (GAD) than in those who have only one of the aforementioned conditions.

Some studies report prevalence rates of up to 45% among people with GAD and up to 56% of those with obsessive-compulsive disorder. Posttraumatic stress disorder is also commonly comorbid with AvPD.

Avoidants are prone to self-loathing and, in certain cases, self-harm. In particular, avoidants who have comorbid PTSD have the highest rates of engagement in self-harming behaviour, outweighing even those with borderline personality disorder (with or without PTSD). Substance use disorders are also common in individuals with AvPD – particularly in regard to alcohol, benzodiazepines and heroin – and may significantly affect a patient’s prognosis.

Earlier theorists proposed a personality disorder with a combination of features from borderline personality disorder and avoidant personality disorder, called “avoidant-borderline mixed personality” (AvPD/BPD).

Causes

Causes of AvPD are not clearly defined, but appear to be influenced by a combination of social, genetic and psychological factors. The disorder may be related to temperamental factors that are inherited.

Specifically, various anxiety disorders in childhood and adolescence have been associated with a temperament characterised by behavioural inhibition, including features of being shy, fearful and withdrawn in new situations. These inherited characteristics may give an individual a genetic predisposition towards AvPD.

Childhood emotional neglect and peer group rejection are both associated with an increased risk for the development of AvPD. Some researchers believe a combination of high-sensory-processing sensitivity coupled with adverse childhood experiences may heighten the risk of an individual developing AvPD.

Subtypes

Millon

Psychologist Theodore Millon notes that because most patients present a mixed picture of symptoms, their personality disorder tends to be a blend of a major personality disorder type with one or

more secondary personality disorder types. He identified four adult subtypes of AvPD as outlined below.

SubtypePersonality Traits/Features
Phobic Avoidant (including dependent features)General apprehensiveness displaced with avoidable tangible precipitant; qualms and disquietude symbolised by a repugnant and specific dreadful object or circumstances.
Conflicted Avoidant (including negativistic features)Internal discord and dissension; fears dependence; unsettled; unreconciled within self; hesitating, confused, tormented, paroxysmic, embittered; and unresolvable angst.
Hypersensitive Avoidant (including paranoid features)Intensely wary and suspicious; alternatively panicky, terrified, edgy, and timorous, then thin-skinned, high-strung, petulant, and prickly.
Self-Deserting Avoidant (including depressive features)Blocks or fragments self-awareness; discards painful images and memories; casts away untenable thoughts and impulses; ultimately jettisons self (suicidal).

Others

In 1993, Lynn E. Alden and Martha J. Capreol proposed two other subtypes of avoidant personality disorder, as outlined below.

SubtypePersonality Traits/Features
Cold-AvoidantCharacterised by an inability to experience and express positive emotion towards others.
Exploitable-AvoidantCharacterised by an inability to express anger towards others or to resist coercion from others. May be at risk for abuse by others.

Diagnosis

ICD

The World Health Organisation’s ICD-10 lists avoidant personality disorder as anxious (avoidant) personality disorder (F60.6).

It is characterised by the presence of at least four of the following:

  1. Persistent and pervasive feelings of tension and apprehension.
  2. Belief that one is socially inept, personally unappealing, or inferior to others.
  3. Excessive preoccupation with being criticised or rejected in social situations.
  4. Unwillingness to become involved with people unless certain of being liked.
  5. Restrictions in lifestyle because of need to have physical security.
  6. Avoidance of social or occupational activities that involve significant interpersonal contact because of fear of criticism, disapproval, or rejection.

Associated features may include hypersensitivity to rejection and criticism.

It is a requirement of ICD-10 that all personality disorder diagnoses also satisfy a set of general personality disorder criteria.

DSM

The Diagnostic and Statistical Manual of Mental Disorders (DSM) of the APA also has an avoidant personality disorder diagnosis (301.82). It refers to a widespread pattern of inhibition around people, feeling inadequate and being very sensitive to negative evaluation. Symptoms begin by early adulthood and occur in a range of situations.

Four of the following seven specific symptoms should be present:

  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 criticised 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 risk or to engage in any new activities because they may prove embarrassing.

Differential Diagnosis

In contrast to social anxiety disorder, a diagnosis of AvPD also requires that the general criteria for a personality disorder are met.

According to the DSM-5, avoidant personality disorder must be differentiated from similar personality disorders such as dependent, paranoid, schizoid, and schizotypal. But these can also occur together; this is particularly likely for AvPD and dependent personality disorder. Thus, if criteria for more than one personality disorder are met, all can be diagnosed.

There is also an overlap between avoidant and schizoid personality traits and AvPD may have a relationship to the schizophrenia spectrum.

Epidemiology

Data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions indicates a prevalence of 2.36% in the US general population. It appears to occur with equal frequency in males and females. In one study, it was seen in 14.7% of psychiatric outpatients.

Criticism

There is controversy as to whether avoidant personality disorder (AvPD) is distinct from generalised social anxiety disorder. Both have similar diagnostic criteria and may share a similar causation, subjective experience, course, treatment and identical underlying personality features, such as shyness.

It is contended by some that they are merely different conceptualisations of the same disorder, where avoidant personality disorder may represent the more severe form. In particular, those with AvPD experience not only more severe social phobia symptoms, but are also more depressed and more functionally impaired than patients with generalised social phobia alone. But they show no differences in social skills or performance on an impromptu speech. Another difference is that social phobia is the fear of social circumstances whereas AvPD is better described as an aversion to intimacy in relationships.

Treatment

Treatment of avoidant personality disorder can employ various techniques, such as social skills training, psychotherapy, cognitive therapy, and exposure treatment to gradually increase social contacts, group therapy for practicing social skills, and sometimes drug therapy.

A key issue in treatment is gaining and keeping the patient’s trust since people with an avoidant personality disorder will often start to avoid treatment sessions if they distrust the therapist or fear rejection. The primary purpose of both individual therapy and social skills group training is for individuals with an avoidant personality disorder to begin challenging their exaggerated negative beliefs about themselves.

Significant improvement in the symptoms of personality disorders is possible, with the help of treatment and individual effort.

Prognosis

Being a personality disorder, which is usually chronic and has long-lasting mental conditions, an avoidant personality disorder is not expected to improve with time without treatment. Given that it is a poorly studied personality disorder and in light of prevalence rates, societal costs, and the current state of research, AvPD qualifies as a neglected disorder.

Book: Pocket Therapy for Anxiety

Book Title:

Pocket Therapy for Anxiety: Quick CBT Skills to Find Calm (New Harbinger Pocket Therapy).

Author(s): Edmund J. Bourne.

Year: 2020.

Edition: First (1st).

Publisher: New Harbinger.

Type(s): Paperback and Kindle.

Synopsis:

Quick, simple, and effective anxiety relief that fits right in your pocket-so you can manage your symptoms anytime, anywhere.

If you suffer from anxiety, you may try to avoid the situations that cause you to feel uneasy. But avoidance is not the answer-and letting your fears and worries constantly hold you back will ultimately keep you from living the life you truly want. So, how can you learn to cope with your anxiety in the moment? This little book can help you face your fears and take charge of your anxiety-wherever or whenever it shows up.

From the author of The Anxiety and Phobia Workbook and Coping with Anxiety, Pocket Therapy for Anxiety offers immediate, user-friendly, and evidence-based strategies to help you manage anxiety, panic, and fear. The exercises in this book can be done in the moment, whenever you feel anxious, and will help you move past your fears and start living the life you were meant to live.

You will learn to:

  • Relax your body and mind.
  • Stop expecting the worst.
  • Get regular exercise and eat right to stay calm.
  • Turn off worry and cope on the spot.
  • And much, much more…

Do not let anxiety keep you one step behind. This little book will show you how to face your fears, overcome panic when it happens, and take charge of your anxiety for good!

What Impact does Motivational Dispositions have on Mood Symptoms & Emotional Regulation?

Research Paper Title

Psychopathological Correlates and Emotion Regulation as Mediators of Approach and Avoidance Motivation in a Chinese Military Sample.

Background

Approach and avoidance motivation have been thoroughly studied in common mental disorders, which are prevalent in the military context.

Approach/avoidance motivational dispositions underlie emotion responses and are thought to influence emotion dysregulation.

However, studies on the mediating role of emotion regulation (ER) between motivational dispositions and mental disorders have been insufficient.

The researchers examined the psychopathological correlates of motivational dispositions and explored the mediating role of ER.

Methods

The Behavioural Inhibition System and Behavioural Activation System (BIS/BAS) scales and measures of mood disorders (depression, anxiety, OCD, and PTSD) were administered to a nonclinical sample of 3,146 Chinese military service members.

The Emotion Regulation Questionnaire for Army men (ERQ-A) (Chinese version) was used to measure ER styles.

They examined the reliability and construct validity of the BIS/BAS scales.

Approach/avoidance motivations were correlated with symptoms of mood disorders.

Mediation analysis was conducted to confirm the mediating role of ER between motivation and mood disorders.

Results

The results showed acceptable internal reliability and construct validity of the BIS/BAS scales. Gender (female), family status (single-parent family), and social relationships (having fewer good friends) were significant predictors of high BIS sensitivity.

More years of education, an older age, being an only child and being in a single-parent family all significantly predicted high BAS sensitivity.

The BIS/BAS scales were predictive of various DSM-V-based mental disorders (depression, anxiety, OCD, and PTSD).

Immersion exacerbated the impact of BAS/BIS sensitivities on depressive/PTSD symptoms, while reinterpretation and talking out alleviated the impact of BAS/BIS sensitivities on these symptoms.

Conclusions

Motivational dispositions have an impact on mood symptoms under specific conditions.

ER strategies (immersion, reinterpretation, and talking out) were shown to be partial mediators between approach/avoidance motivation and mood disorders.

These findings highlight the importance of ER in altering the impact of motivational dispositions on mood disorders and as a promising target of psychotherapies.

Reference

Wang, X., Zhang, R., Chen, X., Liu, K., Wang, L., Zhang, J., Liu, X. & Feng, Z. (2019) Psychopathological Correlates and Emotion Regulation as Mediators of Approach and Avoidance Motivation in a Chinese Military Sample. Frontiers in Psychiatry. 10:149. doi: 10.3389/fpsyt.2019.00149. eCollection 2019.

Would a Clinical Staging Tool be useful in Clinical Practice to Predict Disease Course in Anxiety Disorders?

Research Paper Title

A clinical staging approach to improving diagnostics in anxiety disorders: Is it the way to go?

Background

Clinical staging is a paradigm in which stages of disease progression are identified; these, in turn, have prognostic value.

A staging model that enables the prediction of long-term course in anxiety disorders is currently unavailable but much needed as course trajectories are highly heterogenic.

This study therefore tailored a heuristic staging model to anxiety disorders and assessed its validity.

Methods

A clinical staging model was tailored to anxiety disorders, distinguishing nine stages of disease progression varying from subclinical stages (0, 1A, 1B) to clinical stages (2A-4B).

At-risk subjects and subjects with anxiety disorders (n = 2352) from the longitudinal Netherlands Study of Depression and Anxiety were assigned to these nine stages.

The model’s validity was assessed by comparing baseline (construct validity) and 2-year, 4-year and 6-year follow-up (predictive validity) differences in anxiety severity measures across stages.

Differences in depression severity and disability were assessed as secondary outcome measures.

Results

Results showed that the anxiety disorder staging model has construct and predictive validity.

At baseline, differences in anxiety severity, social avoidance behaviours, agoraphobic avoidance behaviours, worrying, depressive symptoms and levels of disability existed across all stages (all p-values < 0.001).

Over time, these differences between stages remained present until the 6-year follow-up.

Differences across stages followed a linear trend in all analyses: higher stages were characterised by the worst outcomes.

Regarding the stages, subjects with psychiatric comorbidity (stages 2B, 3B, 4B) showed a deteriorated course compared with those without comorbidity (stages 2A, 3A, 4A).

Conclusions

A clinical staging tool would be useful in clinical practice to predict disease course in anxiety disorders.

Reference

Bokma, W.A., Batelaan, N.M., Hoogendoorn, A.W., Penninx, B.W. & van Balkom, A.J. (2019) A clinical staging approach to improving diagnostics in anxiety disorders: Is it the way to go? The Australian & New Zealand Journal of Psychiatry. doi: 10.1177/0004867419887804. [Epub ahead of print].