Cognitive Approaches to Avoidant Personality Disorder and Social Phobia

The DSM-IV-TR states that Avoidant Personality Disorder (APD) is characterized by “A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts” (American Psychological Association, 1994). They must also meet at least four of the following criteria:

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

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

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

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

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

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

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

Persons with APD desire contact with others but become anxious doing so and therefore actively avoid any such contact. Generalized Social Phobia (GSP) is defined as a “persistent, irrational fear of, and compelling desire to avoid, a situation in which the individual is exposed to possible scrutiny by others and fears that he or she may act in a way that will be humiliating or embarrassing” (Herbert, Hope, & Bellack, 1992).

These two disorders no doubt are very similar, and the line between GSP and APD is quite blurred, since all persons diagnosed with APD also meet the criteria for GSP, but it is possible to be GSP and not possess APD as well. The conceptual similarity and apparently high overlap of GSP and APD raise the query of their validity as distinct diagnostic syndromes, and some argue that they are merely different calibers on the same spectrum (Herbert, Hope, & Bellack, 1992). APD tends to be more severe or debilitating, and in a study by Turner, Beidel, & Townsley (1992), it was found that persons with APD appeared to be more generally distressed, have higher levels of anxiety and depression as well as more sensitivity to criticism. They also tend to be much more socially avoidant and were rated as less behaviorally skilled. Also, another major distinction is that socially phobic people tend to avoid specific situations, such as public speaking or large crowds, rather than personal relationships in general (Widiger, & Shea, 1991). Although APD is more chronic and debilitating, and avoids most social situations instead of just specific ones, both APD and SP bring with them a certain level of discomfort.

The onset of both APD and GSP tend to be in early adolescence, usually between the ages of 15 and 20 (Herbert, Hope, & Bellack, 1992). However, this disorder can develop at any age, although it is more likely to appear during adolescence. This disorder is very chronic and long lasting. With respect to actual avoidance, the mean number of years reported was 15.3, and the mean number of years of reported social distress was 20. 9. Social phobia is a definitely a very chronic and unremitting disorder, and often does not get proper treatment. Though it is a very persistent and serious disorder, it can be helped with therapy or medication, as discussed later.

Selective Attention to Angry Faces in Social Phobia

In a study done by Mogg, Philippot, & Bradley (2004), it was discovered that those with social phobia have a selective attention to angry faces, which greatly corresponds with their tendency to be hypersensitive of criticism. It was done by flashing a face pair for either 500 ms or 1,250 ms. Then a probe stimulus (an arrow pointing either up or down) appeared in the location of one of the faces, and the participants were asked to press as quickly and accurately as possible one of two keys that corresponded to the direction of the arrow. Each face pair was displayed twice (64 trials with angry-neutral faces, 64 with happy-neutral faces, 32 with neutral-neutral fillers). There was an equal number of trials in each condition as a function of stimulus duration, emotional face location (left or right), probe location (left or right), and probe type (up or down arrow). The trials were presented in a new, fully random order for each participant (Mogg, Philippot, Bradley, 2004).

The results of this study suggest that individuals with clinical social phobia show an attention bias toward angry faces, being more accurate and quicker to press the key that corresponded with the angry face, relative to the neutral and happy faces. The control group showed no bias for angry or happy faces, and it is suggested that awareness for angry faces was associated with social anxiety. That is congruent with the theory that socially phobic people are hypersensitive to criticism or other negative social interactions (Mogg, Philippot, Bradley, 2004).

Cognitive Patterns and Beliefs of Persons with Avoidant Personality Disorder or Social Phobia

According to Beck’s cognitive theory, an APD persons basic belief is, “I may get hurt,” and their strategy to prevent being hurt is avoidance. Though most people do exhibit some level of avoidance for unpleasant situations, APD persons take their avoidance to the extreme. Persons with ADP are highly sensitive of rejection and criticism, and avoid social or occupational interactions for fear of being shamed or ridiculed. They tend to feel inferior to others or unappealing, and are unwilling to get involved in relationships unless they are certain that they are liked. Also, they tend to be afraid of being abandoned, and may seem too dependent on someone who is important to them, such as their spouse or a close friend (Beck, Freeman, & Associates, 1990).

Some other basic beliefs of APD persons that Beck listed include, “I am socially inept and socially undesirable in work or social situations,” or “It is better not to do anything than to try something that might fail” (Beck, Freeman, & Associates, 2003). Also, their avoidant behavior may cause them to be viewed as lazy, since they may avoid doing a task that is unpleasant or they believe that they will fail at, believing “If I don’t think about a problem, I don’t have to do anything about it. If I ignore a problem, it will go away” (Beck, Freeman, & Associates, 1990). Their low self-esteem makes them believe that no one will like them, and especially not after getting close to them and seeing their faults (“If people get close to me, they will discover the ‘real’ me and reject me,” Beck, Freeman, & Associates, 2003) and thus avoid relationships so they will not be abandoned later after the person “discovers” their faults. Persons with APD also tend to internalize problems and avoid situations that may be potentially harming or embarrassing-even though the threat is usually only cognitive- as a way to prevent being hurt.

The Social Thoughts and Beliefs Scale (STABS) is a 21-item self-report instrument that was developed to assess cognitions in socially phobic patients. The instrument asks the respondents to rate the degree to which a particular statement is typical of their thinking in social situations. Measuring cognitions in social phobia is a significant step in developing understanding of how cognitions might be involved in the treating and accessing the efficacy of the treatment outcome.

Some of the items on STABS include “My mind is very likely to go blank in social situations,” “When other people laugh it feels as if they are laughing at me,” and “If there is a pause in conversation, I feel as if I have done something wrong” (Turner, Beidel, Heiser, & Lydiard, 2003). APD and socially phobic persons tend to internalize everything, and often blame themselves for social problems, some of which are merely perceived (such as gaps in conversation being excruciatingly tense, because they are a bore, or overall catastrophic instead of normal). Both STABS and Beck’s cognitive theory show the faulty cognitions, low self-esteem, and internal attribution style likely to be possessed by socially phobic persons.

The Relation of Self-Discrepancies and Social Phobia

Self-discrepancies are cognitions that can be the source emotional distress. Most psychological theories of emotional disorders reason that self-evaluation processes are associated with vulnerability to distress, and that there is a correlation between low self-esteem and depressed mood. Self-discrepancy theory suggests that certain types of discrepancy between self-state are associated with negative motivational and emotional states.

There are two kinds of actual self-inconsistency that are associated with a vulnerability to depression versus anxiety. These two self-discrepancies differ in the domain (ideal vs. ought) and standpoint (own vs. other). In an actual/own:ideal/own discrepancy, the individual’s actual attributes do not match the ideal state that he or she personally desires to achieve. In an actual/own:ought/other discrepancy, the individual’s actual attributes do not match the state in which they believe another person, who is close to them (such as a parents or a spouse), would like him or her to fulfill (Strauman, 1989).

The first self-discrepancy is commonly associated with depression, and the latter is associated with anxiety. Social phobics tend to believe that they are not good enough, or do not meet the level of accomplishment that the people around them believes that they should. As congruent with the other studies or scales, socially phobic persons tend to have low self esteem and do not think that they are good enough for the people around them, even though it is not true (Strauman, 1989).

Social Phobia and Occupation

Another study examined whether social phobics were different from non-anxious controls in terms of occupational adjustment. Their results showed vast contrasts between the phobics and the controls, as expected. The social phobics tended to be underemployed and believed that their supervisor would rate them as less dependable and less likely to advance, though their performance was no lower than the controls. Since they are hypersensitive to criticism, they take criticism or even suggestions from their superiors very personally, and also tend to internalize the comment. That, in turn, only adds to their negative cognitions and beliefs that their supervisors would rate them lowly, even though their performance was fine. They also tend to try to have less interpersonal occupations. This study shows how social phobia can be fairly debilitating, and also the negative cognition that socially phobic persons tend to have (Monroe, Fallon, & Heimberg, 2003).

Blushing and its Relation to Social Phobia

Though social phobia tends to be more of an internal or mental disorder and faulty cognitions, it does have a few physical symptoms such as sweating or blushing. Blushing is the most prominent physical symptom of social phobia, and the fear of the perception of their visible anxiety symptoms is an important part of cognitive-behavioral models of social phobia.

In a study of thirty social phobic persons, half of whom were concerned about blushing, and 14 control participants were assessed while watching an embarrassing videotape, holding a conversation, and giving a talk. Socially phobic persons tend to be afraid of embarrassment, or showing signs of embarrassment such as blushing. The study found that only when watching the video did the social phobic participants blush more than control. The social phobic persons who were concerned about blushing did not, in fact, blush more intensely than their phobic counterparts who were not concerned. They did have higher heart rates, though, which is a possible reflection of a higher arousability. Their higher heart rates may also cause them to feel as if they are blushing, thus increasing their fear of it when around other people (Gerlach, Wilhelm, Gruber, & Roth, 2001).

Treatments for Avoidant Personality Disorder and Social Phobia

Currently, the most effective treatment for social phobia is cognitive-behavioral therapy. In a study by Hofmann, Moscovitch, Kim, & Taylor (2004), they randomly assigned ninety individuals with social phobia to a waitlist control group, a cognitive-behavioral therapy group, or an exposure therapy group, which only targeted behavior without explicit cognitive intervention. The waitlist group was the control and received no treatment. The exposure therapy included repeated in vivo exposures to social situations, video feedback, didactic training, as well as weekly homework assignments. The exposure therapy also focused primarily on the patients’ public speaking anxiety, while the patients in the CBT group were taught to identify automatic negative cognitions, observe the correlation between anxiety and their cognitions, examine their thinking errors, and formulate rational alternatives to them. They were also given some exposure therapy and participated in some self-perception tests, in which they could work on their self-perception and its discrepancies. Cognitive-behavioral therapy can help with self-discrepancies, and to teach them to see that the standards they think other people have of them are either only perceived, or not nearly as high as they believe them to be (Hofmann, Moscovitch, Kim, & Taylor, 2004).

Both treatments aimed to reduce the level of social anxiety, as well as reducing negative cognitions. Both of the treatments were effective and produced comparable results in reducing the level of anxiety negative self-focused thoughts. There was little or no improvement on positive self-focused thoughts, which support the notion that changes in social anxiety are associated distinctively by a decrease in negative self-perception, rather than an increase in positive.

Though both treatments produced comparable results, however, only the participants who received cognitive-behavioral therapy showed continued improvement in a 6-month follow-up after the treatment. Though exposure therapy may have produced initial results, the subjects were likely to relapse (at least partially) and the results were not entirely permanent. This makes sense since social phobia tends to be based on negative cognitive processes, so targeting and shaping those would be much more effective than only exposing the individual to their fear. The study shows that CBT is currently the best therapy for social anxiety, since it focuses on their cognitions, which is what their anxiety stems from, as well as exposing them to their social fears (Hofmann, Moscovitch, Kim, & Taylor, 2004).

Some medications, though, have also been shown to help social anxiety. There are currently three antidepressants that may be useful in the treatment of social phobia: paroxetine, sertraline and venlafaxine. Paroxetine and sertraline are SSRIs, while venlafaxine is a combination of a norepinephrine and SSRI. They have all shown efficacy in the treatment of social phobia, but like all medications, some people have been shown to be non-responsive to them. The combination of medication and CBT has also been seen to help social phobia.

Other drugs are also being studied as possible treatments, such as monoamine oxidase inhibitors (MAOIs). They seem to be successful in some cases, but there are concerns regarding their safety. The side effects typically associated with MAOIs include a risk of serotonin syndrome or hypertensive reactions when combined with certain foods or other medications. Currently they are only used in studies. Benzodiazepines, such as alprazolam and clonazepam, are effective for providing rapid relief for recurring episodic and as-needed dosing. It is not recommended for long-term treatment, however, because of its many side effects. Some of those side effects include sedation, cognitive dulling, as well as a risk for abuse and dependence, or even withdrawal. Though not recommended for long-term usage, it does provide instant relief that may be useful in specific situations (Feldman, Rivas-Vazquez, 2003).

Conclusion

Avoidant Personality Disorder and Social Phobia are very similar, and centers around the characteristic of an irrational fear of social situations, which usually stems from negative cognitions as well as self-discrepancies. APD tends to be more chronic or debilitating that social phobia, but they are essentially just different calibers on the same spectrum. Both APD and SP persons tend to be hypersensitive to criticism, and have a tendency to internalize problems, both real and perceived. Both are pervasive disorders that involve a pattern of social inhibition and feelings of inadequacy, which are caused by their negative cognitions and self-discrepancies, as well as a selective attention to angry faces. They also tend to be lonely, and though they want social interactions or relationships, but are extremely anxious or fearful and avoid people as a result of that anxiety.

Social phobics tend to have low self esteem and do not think that they are good enough for the people around them, and though they desire contact with others, they become increasingly anxious while doing so and therefore avoid other people to avoid being hurt, ridiculed or rejected. They choose occupations that require little interpersonal interaction, and are worried than their supervisors think lowly of them, even though their performance is not any lower than their co-workers.

They also tend to over process social situations and internalize anything that goes wrong. They often blame themselves for social problems, some of which are merely perceived, such as gaps in conversation being unbearably tense and because he or she is a bore to the person they are conversing with. Sometimes the perceived problem may even include physical symptoms such as blushing even if they really are not.

Social phobia is definitely a chronic disorder, but may be helped by cognitive-behavioral therapy, which teaches patients to recognize their negative cognitions and change them, as well as expose them to feared social situations. The combination of the cognitive and behavioral therapy seems to work well for those with social phobia, and is more effective and longer lasting than exposure therapy on its own. Some antidepressants may also be of assistance in treating social anxiety. Though Avoidant Personality Disorder and social phobia are persistent and relentless disorders that can be fairly debilitating, treatments such as cognitive-behavioral therapy or antidepressants are promising treatments.

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