Social anxiety and avoidant personality: Discrete or continuous disorders?

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1 Star 2002: Under the Southern Cross Proceedings of the 23 rd Stress and Anxiety Research Conference pp Social anxiety and avoidant personality: Discrete or continuous disorders? Kerryn Baker-Smith, Kathleen A Moore & David J Mellor Deakin University, Melbourne Australia Research indicates that generalised social phobia is comorbid with avoidant personality disorder in approximately 80% of cases. This high level of comorbidity is not particularly surprising given that there is a significant overlap in the diagnostic criteria for each of these disorders. In the DSM-IV-TR, the criteria for avoidant personality disorder and social phobia both include: (a) avoidance of social or occupational situations; (b) avoidance of social or performance situations because of a fear of being shamed or criticised; and (c) a fear of participating in situations which may result in embarrassment (American Psychiatric Association [APA], 2000). However, avoidant personality disorder has additional criteria which suggest greater impairment, including (a) unwilling to socialise unless certain of being liked; (b) inhibition in social situations due to feelings of inadequacy and (c) view of self as socially incompetent, unappealing, or inferior to others (APA, 2000). Research has indicated that while both groups share associated symptomatolgy, people suffering with avoidant personality disorder experience higher levels of comorbid anxiety and depression, and greater impairment in their level of social skills than people suffering with social anxiety. However, people with these disorders might report similar levels of attenuated social support and social relationships, poor physical health status, and the use of less adaptive coping strategies. It is possible that people suffering from both diagnoses experience minimal levels of social support because they fear (and therefore avoid) situations that involve socialisation and meeting people. The avoidance behaviours common to both disorders might have implications for symptom recognition and for health-seeking behaviours. This paper will explore the similarities and differences between avoidant personality disorder and generalised social phobia, and the possibility that these disorders lie on a continuum of social anxiety. Research shows that approximately 80% of people with Generalised Social Phobia (GSP) also suffer from Avoidant Personality Disorder (APD) (e.g., Hofmann, Newman, Ehlers, & Roth, 1995). This high rate of comorbidity is likely to be a result of the overlap in diagnostic criteria for each of these disorders, and has led to an ongoing debate about the distinctness of GSP and APD. It is argued in this paper that GSP and APD lie on a continuum of severity of symptoms, which includes shyness, social anxiety, social phobia (discrete), GSP and APD. It is also proposed that, like people with social anxiety, individuals who suffer from GSP and APD may have similar but more extreme difficulties with social support, relationships, physical health and coping strategies. Implications for the treatment of individuals with GSP and APD will be discussed. The DSM-IV-TR criteria for social phobia state that affected individuals experience a marked and constant fear of social or performance situations in which they believe that they will experience embarrassment and humiliation (APA, 2000). Due to this fear of embarrassment, people with social phobia typically avoid the feared situations, or they may force themselves to endure the situations but experience intense anxiety. Extreme anticipatory fear is also likely, whereby individuals experience intense worry in advance of the feared situation. This anticipatory anxiety is often followed by fearful cognitions such as thinking that they will be unable to cope in the situation, and anxiety symptomatology (including sweating, muscle tension, blushing, confusion and palpitations), which leads to actual or perceived inadequate performance in the feared situation. This inadequate performance results in a circular process whereby the person experiences embarrassment and anxiety, which then leads to increased anticipatory anxiety prior to a later feared situation or to actual avoidance of the situations (APA, 2000). Of course, not all people experience social anxiety with such a degree of severity, but nevertheless these feelings can still be debilitating. Gee and Moore (1997) demonstrated a continuum between shyness, feelings of social anxiety, and a diagnosis of social phobia, although the DSM-IV-TR (APA, 2000) suggests that social phobia is more severe than normal shyness. It is also possible that this continuum might include, at the more severe end, avoidant personality disorder. The DSM-IV-TR (APA, 2000) indicates that when the person s fears are related to most social situations (such as initiating and maintaining conversations, dating, speaking to people in authority and going to parties), the specifier Generalised can be used. 14

2 Individuals diagnosed with Generalised Social Phobia (GSP) typically fear both performance situations and social situations. When compared to individuals whose fears are more specific, those diagnosed with the Generalised specifier usually manifest deficits in social skills and experience more significant social and work impairment (APA, 2000). The DSM- IV-TR also clearly states that when individuals fear most social situations, and therefore receive the Generalised specifier, a diagnosis of Avoidant Personality Disorder should also be considered. However, in many instances, individuals fear more than one situation or type of situation, so the term GSP is typically more applicable. Although some authors differentiate between GSP and specific SP (e.g., Norton, Cox, Hewitt, & McLeod, 1997), Moore and Gee (2002) found only one factor on their Social Phobia Inventory (SoPhi). The SoPhi contains a list of fears and feared situations but confirmatory factor analysis revealed that situations did not load onto separate factors. They suggested that the generalised nature of social anxiety might be more prevalent than specific fears. According to the DSM-IV-TR, individuals with Avoidant Personality Disorder (APD) experience a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation (APA, 2000). This condition begins by early adulthood and is experienced in a variety of situations. Millon (1981) described individuals with APD as people who have a great desire for contact with others but become anxious doing so. As a result of their anxiety, these individuals actively avoid such contact. They are sensitive and aware of environmental cues, however they are left isolated because they lack trust in others and confidence in themselves (Millon, 1981). The similarities and differences between GSP and APD in terms of diagnostic criteria and also the presentations of people suffering from these disorders are discussed below. The DSM-IV-TR supports comorbid diagnoses of GSP and APD, by suggesting that the additional diagnosis be considered for those who fit the Generalised specifier for Social Phobia (APA, 2000). Although the similarities between these disorders perhaps do indicate that some individuals should be given comorbid diagnoses, the implications of this in terms of intervention and the possible increased distress of being diagnosed as having two disorders is an important consideration. As far as we are aware, there has only been one study that has investigated the comorbidity of APD and GSP using DSM-IV criteria and this was a study by McGlashan et al., reported by Rettew (2000) as in press. Rettew cited the rate of GSP in the 157 APD patients who participated in the McGlashan et al. study as 38%. A rate significantly higher than that found for other personality types, this finding can be interpreted to suggest that individuals experiencing GSP are more likely to have an avoidant personality type than any other personality type. Conversely, it might also be interpreted to mean that people in the study of GSP patients could be differentiated in terms of severity of their GSP. In a review of the literature, Rettew (2000) reported that studies that have investigated the rate of comorbidity of APD in patients with GSP using previous versions of the DSM have indicated that the rate ranges from 25% to 89%, while studies investigating the rate of comorbidity of GSP in patients with APD report a range of 25% to 100%. According to Rettew, these fairly large ranges may be a result of varying populations as well as different strategies for recruitment and diagnosis. However, regardless of the cause of the range in comorbidity rates, these figures suggest that even in the studies that found the lowest rate of comorbidity, there was still a significant overlap in the presentation of these two disorders. There is perhaps no clearer method for demonstrating the similarities between GSP and APD than by presenting the DSM-IV-TR criteria for both disorders. Table 1 contains the diagnostic criteria for these two disorders, and from it can be seen the high overlap in the characteristics of individuals who suffer from these disorders (Note: the criteria are presented in a different order to that in the DSM-IV-TR to allow for easier comparison). The diagnostic criteria for GSP and APD outlined in Table 1 indicate significant overlap between these disorders particularly in relation to fears of being judged by others, avoidance of situations in which judgment may occur and the significant impact these fears and avoidance behaviours have on the individual s life. It is also clear from Table 1 that people who meet four of the seven diagnostic criteria for a diagnosis of APD, would also meet the criteria for GSP. In fact, the DSM-IV-TR (APA, 2000) actually states that there appears to be a great deal of overlap between Avoidant Personality Disorder and Social Phobia, Generalised Type, so much so that they may be alternative conceptualisations of the same or similar conditions (p. 720). 15

3 The major difference between the two disorders appears to relate to the GSP criteria where people must fear acting in a way that is embarrassing or humiliating, whereas people with APD have a fear of being rejected or criticised no matter how they act (Rettew, 2000). In terms of operationalising these criteria, Turner, Beidel, and Townsley (1992) found differences between people with GSP and APD on measures of anxiety, social anxiety and social functioning. Likewise, Herbert, Bellack, and Hope (1992) found that APD is associated with higher levels of anxiety, fear of negative social evaluation, social distress, depression and global psychopathology. Considering that the differences between the two disorders was merely a distinction related to severity of symptoms, Herbert et al. concluded by questioning the validity of the two disorders as separate diagnostic entities. Many researchers have suggested that due to the high overlap and conceptual similarities between these two disorders, it may be more appropriate to distinguish severe social anxiety and avoidance in another way (Herbert et al., 1992). We suggest that conceptualising the symptoms of GSP and APD in terms of a continuum of shyness, social anxiety and avoidance might provide such a method. This proposition is strengthened by research that has compared the characteristics of GSP and APD and yielded few differences, with the main distinction being the severity of symptoms for the two disorders (Rettew, 2000). Specifically, some studies (e.g., Turner, Beidel, Daneu, & Keys, 1986; Holt, Heimberg, & Hope, 1992) found that APD may simply be a more severe form of GSP in terms of symptom levels, anxiety, avoidance and depression. These data further indicate that these disorders are so similar that they in fact lie on a continuum rather than being distinct disorders, with GSP at the less severe end and APD at the more severe end of the continuum. If these are not truly distinct disorders, the high levels of comorbidity separated in the literature are, in fact, artificial. Gee and Moore (1997) have proposed such a continuum between shyness, feelings of social anxiety and social phobia, and it is possible that this could be extended to include APD at the more severe end, primarily due to the breadth of impact on the sufferer. Individuals with GSP experience the impact of their disorder in a variety of situations, while individuals with SP are affected in fewer situations. The continuum presented here suggests that shyness, social anxiety, SP, GSP and APD are similar in terms of their main characteristics, but that they differ on the severity of symptoms. This continuum is an attempt to clarify the distinction between GSP and APD and proposes that the similarities and differences between these disorders extend to less debilitating conditions, including shyness and social anxiety. Aside from differences in the severity of symptoms among people with SP, GSP and APD, and the relationship between these disorders, it might also be informative in terms of the continuum hypothesis and treatment options to assess the impact of these disorders on individuals social support, relationships, physical health and coping strategies. Despite the importance of these factors on well-being, few researchers have investigated the extent of the impact of these disorders on them. The term social support is used to refer to the many different types and aspects of social relationships (Eurelings-Bontekoe, Verschuur, & Diekstra, 1996). Bolger and Eckenrode (1991) have found that high levels of social anxiety are associated with low levels of social support. People with high levels of social anxiety have also been found to have fewer best friends and more friendships that are low in companionship, intimacy and emotional support (LaGreca & Lopez, 1998). People who are socially avoidant also have fewer friends and are less likely to develop new friendships that involve an intimate connection (Vernberg, Abwender, Ewell & Beery, 1992). Considering that anxiety and avoidance are central characteristics of GSP and APD, it is likely that individuals suffering from these disorders will experience these negative effects on social support. Specifically, people who suffer from GSP and APD avoid social situations due to the fear of being embarrassed or humiliated in such situations. Thus, they avoid the level of human contact necessary to establish supportive social networks. This avoidance can contribute to high levels of loneliness and isolation while at the same time reinforce individuals perceptions that they are unable to cope with social situations. 16

4 Table 1 Diagnostic Criteria for Social Phobia and Avoidant Personality Disorder Social Phobia * A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people and fears doing something embarrassing. * Exposure to the feared situation almost invariably provokes anxiety. * The feared situations are avoided or else endured with intense anxiety or distress. * The avoidance, anxious anticipation, interferes with the individual s normal routine, occupational functioning, or social activities or relationships. * The person recognises that the fear is excessive or unreasonable. Avoidant Personality Disorder * A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, and a preoccupation with being criticised or rejected in social situations. * Is inhibited in new interpersonal situations because of feelings of inadequacy. * Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection. * Is unwilling to get involved with people unless certain of being liked * Shows restraint within intimate relationships because of the fear of being shamed or ridiculed. * Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing (Nb: Social Phobia - Specify if Generalised : if the fears include most social situations) Hammerlie, Montgomery, and Melchers (1988) found that individuals with GSP do indeed generally have poor social support networks, less intimate social interactions and fewer social relationships. According to Moore (1999), even in close relationships individuals who are socially anxious fear being evaluated and therefore avoid disclosing their personal feelings. Avoidance, which we suggest can be a lack of emotional engagement as well as physical avoidance, is likely to further increase the lack of relationship quality, such as intimacy and companionship, and may lead to feelings of inadequacy in relationships and further avoidance of personal disclosure. This avoidance of personal disclosure may affect other areas of life, such as physical health. Physical Health Although there is limited research in the area of physical health for people with APD and GSP, these individuals may be at a higher risk for physical health problems due to their avoidance behaviours. As well as their avoidance of social situations, it is likely that these individuals avoid other situations where they may feel that they are being judged or evaluated, or where they may feel embarrassed by the social exchange or the need to disclose about the self. Such a situation might occur with respect to doctor s appointments. Such embarrassment may inhibit both regular checkups and even presentations for specific symptoms. George and Lydiard (1994) found that social anxiety frequently occurs with tremor and stuttering, and Lydiard and Falsetti (1999) found that social anxiety was associated with irritable bowel syndrome. Although it is difficult to determine cause and effect, it is also possible that these particular conditions might be part of the constellation of anxiety symptoms. 17

5 Shyness SP GSP APD Less severe > > > More severe - socialises despite some discomfort - fear leads to avoidance - avoids social situations - minimal anxiety socialising - high anxiety - intense anxiety - social support available - few friendships - high depression - satisfying friendships - low intimacy - physical illness - low companionship - alcohol dependence - lack of coping strategies - high social distress - more psychopathology Figure 1. Continuum from shyness to Avoidant Personality Disorder Randall, Thomas and Thevos (2001) have stated that 20% of people with social phobia are dependent on alcohol to reduce their anxiety symptoms. Clearly, people with social anxiety who use alcohol to cope are at an increased risk for liver damage (Gordon & Kannel, 1984), cancer (Driver & Swann, 1987), and cardiovascular problems (Klatsky, 1987), which can result from alcohol consumption. Coping According to Pearlin and Schooler (1978), coping is defined as behaviour that serves to protect people from psychologically damaging social experiences. People utilise social resources, psychological resources, and specific coping responses when coping with stressors. Social resources include social networks such as family, friends, colleagues, and neighbours (Pearlin & Schooler, 1978). Psychological resources are the personality characteristics of the individual that help to withstand threats in the environment, while specific coping responses are the behaviours, cognitions and perceptions in which the individual engages when actually experiencing life problems (Pearlin & Schooler, 1978). As discussed above, individuals who suffer from APD and GSP are likely to have fewer friendships, and particularly less intimate friendships, than individuals without these disorders (e.g.,vernberg et al., 1992). Their ability to use social support as resources to cope is likely to be reduced. With regard to psychological resources, individuals with APD and GSP have been found to avoid, rather than withstand, threats and pressures in the environment (Moore, 1999). Moore found that socially anxious individuals frequently use affective coping strategies such as self-blame, avoidance and wishful thinking, rather than solution focused coping. Further, people with GSP and APD might experience negative cognitions in social situations, which impede their ability to use appropriate coping strategies. In fact, Mellings and Alden (2000) have summarised the main cognitive processes that people with social anxiety experience in social situations as: (1) selective attention to negative information; (2) biases in judgments; and, (3) exacerbation of social fears. It is unlikely, then, that while experiencing these negative cognitive processes individuals will employ effective coping strategies. Due to their lack of social support, psychological resources and specific coping strategies, it seems likely that individuals with GSP and APD are lacking in the most important areas when it comes to coping with life experiences. Therefore, developing appropriate coping resources may be a crucial part of treatment when working with these individuals. Implications for treatment The similarities between GSP and APD present some important issues in terms of treatment strategies. The research presented above indicates that GSP and APD lie on a continuum that includes shyness, social anxiety, SP, GSP and APD. One implication of this is that individuals with GSP and APD have more extensive avoidant behaviours than the less severe conditions and individuals with these disorders may be less likely to present for treatment. On the other hand, if they do seek treatment, individuals with GSP and APD may require a more intensive treatment program. The strategies that need to be incorporated into such a program include graded exposure to social situations to 18

6 overcome the avoidance that is typical of GSP and APD. The development of coping strategies in people with GSP and APD is also crucial to assist them to manage in social situations despite feelings of anxiety and fear. Prevention of GSP and APD could be targeted at schools and could include ensuring that children and adolescents receive practice in public speaking at school through compulsory assignments involving presentation of information to their peers. Encouraging students to participate in sporting competitions and school dances is another avenue for familiarising younger people to performance and social situations. The implementation of these strategies will assist individuals to develop confidence in performing in front of others and in building up social skills and social networks. References Alden, L. E. (1993). Avoidant personality disorder: Interpersonal problems as predictors of treatment response. Behaviour Therapy, 24, American Psychological Association. (2000). Diagnostic and statistical manual of mental disorders text revision (4 th ed.). Washington, DC: Author. Bolger, N., & Eckenrode, J. (1991). Social relationships, personality, and anxiety during a major stressful event. Journal of Personality and Social Psychology, 61, Driver, H. E., & Swann, P. F. (1987). Alcohol and human cancer. Anticancer Research, 7, Eurelings-Botenkoe, E. H. M., Verschuur, M., & Diekstra, R. F. W. (1996). Symptomatology, social support and social support seeking: Long-term results of a prospective study among primary mental health care patients. Patient Education and Counseling, 28, Gee, D. L., & Moore, K. A. (1997). Social phobia and shyness: Orthogonal or continuum? Paper presented at the Australian Psychological Society 32 nd Annual Conference, Cairns, Australia. George, M. S., & Lydiard, R. B. (1994). Social phobia secondary to physical disability: A review of benign essential temor (BET) and stuttering. Psychosomatics, 35, Gordon, T., & Kannel, W. B. (1984). Drinking and mortality: The Framingham study. American Journal of Epidemiology, 120, Haemmerlie, F. M., Montgomery, R. I., & Melchers, J. (1988). Social support, perceptions of attractiveness, weight, and the CPI in socially anxious males and females. Journal of Clinical Psychology, 44, Herbert, J. D., Bellack, A. S., & Hope, D. A. (1992). Validity of the distinction between generalised social phobia and avoidant personality disorder. Journal of Abnormal Psychology, 101, Hofmann, S. G., Newman, M. G., Becker, E., Taylor, C. B., & Roth, W. T. (1995). Social phobia with and without avoidant personality disorder: Preliminary behaviour therapy outcome findings. Journal of Anxiety Disorders, 9, Hofmann, S. G., Newman, M. G., Ehlers, A., & Roth, W. T. (1995). Psychophysiological differences between subgroups of social phobia. Journal of Abnormal Psychology, 104, Holt, C. S., Heimberg, R. G., & Hope, D. A. (1992). Avoidant personality disorder and the generalised subtype of social phobia. Journal of Abnormal Psychology, 101, Klatsky, A. L. (1987). The cardiovascular effects of alcohol. Alcohol and Alcoholism, 22, La Greca, A. M., & Lopez, N. (1998). Social anxiety among adolescents: Linkages with peer relations and friendships. Journal of Abnormal Child Psychology, 26, Lydiard, R. B., & Falsetti, S. A. (1999). Experience with anxiety and depression treatment studies: Implications for designing irritable bowel syndrome clinical trials. American Journal of Medicine, 107, 65S-73S. Millon, T. (1981). Disorders of Personality: DSM-III, Axis II. New York: Wiley. Moore, K. A. (1999). Social anxiety: Predictors and outcomes. Australian Journal of Guidance and Counselling, 9, Moore, K.A., & Gee, D.L. (2002). Evaluative and predictive properties of the Social Phobia Inventory (SoPhI). Norton, G. R., Cox, B. J., Hewitt, P. L., & McLeod, L. (1997). Personality factors associated with generalised and nongeneralised social anxiety. Personality and Individual Differences, 22, Pearlin, L. I., & Schooler, C. (1978). The structure of coping. Journal of Health and Social Behaviour, 19, Randall, C. L., Thomas, S., & Thevos, A. K. (2001). Concurrent alcoholism and social anxiety disorder: A first step toward developing effective treatments. 19

7 Alcoholism: Clinical and Experimental Research, 25, Rettew, D. C. (2000). Avoidant personality disorder, generalised social phobia, and shyness: Putting the personality back into personality disorders. Harvard Review of Psychiatry, 8, Turner, S. M., Beidel, D. C., Daneu, C. V., & Keys, D. J. (1986). Psychopathology of social phobia and comparison to avoidant personality disorder. Journal of Abnormal Psychology, 95, Turner, S. M., Beidel, D. C., & Townsley, R. M. (1992). Social phobia: A comparison of specific and generalised subtypes of avoidant personality disorder. Journal of Abnormal Psychology, 101, Vernberg, E. M., Abwender, D. A., Ewell, K. K., & Beery, S. H. (1992). Social anxiety and peer relationships in early adolescence: A prospective analysis. Journal of Clinical Child Psychology, 21, Correspondence to: Kate Moore, PhD, School of Psychology Deakin University, 221 Burwood Hwy Burwood 3125 Australia kmoore@deakin.edu.au 20