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Running head: CRITICAL FACTORS
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Critical Factors Involved in a Move from Generalized Social Phobia to an
Experience of Avoidant Personality Disorder from an Adlerian’s Perspective
A Research Paper
Presented to the Faculty of Adler Graduate School
___________________________
In Partial Fulfillment of the Requirements for
Degree of Master of Arts in
Adlerian Counseling and Psychotherapy
___________________________
By:
Marcus Rohrbauck
September 2012
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Abstract
The diagnostic criteria for Generalized Social Phobia and Avoidant Personality Disorder show
considerable overlap between the two disorders, making accurate diagnosis difficult if not
impossible. Since the publication of the DSM III there have been contradictory explanations of
how to interpret the experience of these orders, whether they can coexist, or if they are distinct.
Are these separate disorders or do they lay on a continuum? Due to the fact that the DSM is
currently a categorical system of diagnosis clinicians must be able to provide clear distinctions
between these disorders and up until this point it has failed to do so. Presupposing that these
disorders do indeed lay on a continuum this review of the literature identifies the critical factors
that lead an individual from an experience of Generalized Social Phobia to Avoidant Personality
Disorder. Additionally, the American Psychiatric Association has outlined proposed revisions to
the DSM-5 slated to be released in May of 2013. A shift towards the adoption of a hybrid
categorical and dimensional model of personality disorder diagnosis has been suggested which
may finally put an end to this debate.
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TABLE OF CONTENTS
Abstract……………………………………………………………………………..2
Introduction……………………...………………………………………………....4
Psychopathology……………………………………………………………………7
Kurt Adler and Psychosis…………………………………………………………...11
Mental Illness and Choice…………………………………………………………..11
Historical Comparison of DSM Editions…………………………………………...16
Etiology of Anxiety………………..………………………………………………..17
Social Anxiety Disorder and DSM-IV-TR………………………………………….19
Avoidant Personality Disorder and DSM-IV-TR…………………………………...22
Sperry’s View of Personality Disorders……………………………………………..23
Distinction between Disorders………………………………………………………26
One Disorder on a Spectrum………………………………………………………...27
Critical Factors and Discussion……………………………………………………...29
Arguments for a Dimensional Shift in Diagnosis…………………………………....31
Personality Disorders and DSM-5…………………………………………………...36
Avoidant Personality Disorder and DSM-5………………………………………....37
Social Anxiety Disorder and DSM-5………………………………………………..39
Does DSM-5 End the Continuum Debate?.................................................................42
Clinical Implications…………………………………………………………………43
References……………………………………………………………………………48
Table 1, Characteristic differences between GSP and AVPD……………………….27
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Critical Factors Involved in a Move from Generalized Social Phobia to an
Experience of Avoidant Personality Disorder from an Adlerian’s Perspective
According to the DSM-IV-TR “there appears to be a great deal of overlap between
Avoidant Personality Disorder and Social Phobia, Generalized Type, so much so that they may
be alternative conceptualizations of the same or similar disorders” (APA, 2000 p.720). Due to
this overlap researchers such as Krueger & Eaton (2007), Ruscio, (2010) Turner, Beidel, &
Townsley (1992), Sperry (2003), and many others have sought to determine the significant
factors involved in sufficiently distinguishing these disorders. To elucidate which factors lead an
individual from an experience of Generalized Social Phobia (GSP) to an experience of Avoidant
Personality disorder (AVPD) many factors and perspectives must be considered. This review of
the literature includes a historical comparison of the Diagnostic and Statistical Manual of Mental
Disorders (DSM) from the third edition by the APA (1980) to the current fourth text revised
(TR) by the APA (2000) version which will illustrate how the American Psychiatric Association
(APA) over the past 32 years (since 1980) has sought and failed to resolve this debate.
By first explaining the development of psychopathology from an Adlerian perspective
based on the writings of Ansbacher & Ansbacher (1956), Griffith & Powers (2007), and Sisk
(2010) the experiences of Generalized Social Phobia and Avoidant Personality Disorder will be
presented. This dichotomy sets the stage for a discussion across a broad range of topics
including: an Adlerian conceptualization of mental illness and how it relates to the DSM,
whether mental illness is determined or a choice, and the problems with placing an arbitrary
separation between Axis I and Axis II disorders. This final claim that the separation between
Axis I and Axis II is arbitrary is supported by researchers Krueger & Eaton (2010) and their
claims will be described in this analysis. The presentation of these topics will illustrate the need
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for a paradigm shift in mental health diagnosis by the inclusion of a dimensional model in both
Axis I and Axis II diagnoses.
Adlerian Etiology
Before any discussion of the manifestation of any psychopathology can be undertaken the
underlying root cause of all pathology must be acknowledged. According to Alfred Adler all
psychopathology stems from feelings of inferiority and discouragement (Ansbacher &
Ansbacher, 1956). Everyone is born into the world in a position of less than others for example;
an infant is dependent upon its parents to meet its needs. A child, though more developed than an
infant is still inferior in terms of their physicality to adults. They are short in stature and unable
to reach things in high places, for example. Their brains are still developing and so they are also
cognitively inferior to adults (Ansbacher & Ansbacher, 1956). Rudolph Dreikurs, a
contemporary of Adler suggested that “children are expert observers but make many mistakes in
interpreting what they observe” (Dreikurs & Soltz, 1964, p. 15).
The consequence of this is that children make mistakes in their thinking and misinterpret
the meaning of life experiences (Dreikurs & Soltz, 1964). Adler referred to this
misinterpretation as a Mistaken Belief (Ansbacher & Ansbacher, 1956). If Mistaken Beliefs
develop and are not corrected these beliefs may hinder the development of a socially interested
individual. To understand the development of the personality or Lifestyle of an individual one
must look at their family of origin.
An individual’s family of origin is defined as anyone in that child’s immediate family;
this would be traditionally defined as mother, father, and siblings (Ansbacher & Ansbacher,
1956). However, many families today are blended and so the definition can be broadened to
whoever is relevant and important to the individual. The family is the first social system a child
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is placed in, followed by the school system, and later society as a whole. Within these social
contexts a child develops beliefs about self, the world, the way it works and ought to work, what
men are like, and what women are like (Ansbacher & Ansbacher, 1956).
Adlerian theory also fits into a multicultural model because a child’s beliefs and
Mistaken Beliefs can be identified no matter what the cultural background is. For example, a
Hispanic adult (male) could describe an Early Recollection about his uncle. This early
recollection would reflect the Hispanic man’s beliefs about self and the way the world works.
These beliefs would also reflect the individual’s Hispanic culture and so regardless of the
cultural differences between the client and their therapist the process of Individual (Adlerian)
therapy would be the same.
According to Ansbacher & Ansbacher (1956) the Lifestyle is set by the age of 5 or 6
based on the child’s experiences. Lifestyle refers to a person’s characteristic pattern of
movement in the world. Life is about movement, purposive movement towards a goal. All
behavior has a purpose and that purpose is strive towards what Adler described as the Final
Fictional Goal. Ansbacher and Ansbacher explained the basic goals identified by Adler are a
need for safety, belonging, and significance. Adler also described the tasks of life first described
by Freud which are to love and to work; Adler emphasizing the significance of the social context
added the task of friendship/community (Ansbacher & Ansbacher, 1956).
To be psychologically healthy an individual must meet these basic needs and find a
balance between the tasks of life. In addition to or perhaps most importantly Adler explained that
they must do so in a socially interested manner (Ansbacher & Ansbacher, 1956). Social Interest
is defined as an interest in the interests of others. According to Ansbacher & Ansbacher (1956)
Adler defined Social Interest in the following quote: “to see with the eyes of another, to hear
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with the ears of another, and to feel with the heart of another” (p. 135). The degree to which
Social Interest is present in an individual determines their level of mental health. Adler referred
to Social Interest as the barometer of a child’s mental health (Ansbacher & Ansbacher, 1956).
Adlerian therapy focuses on analyzing an individual’s family of origin including birth
order, Early Recollections (which reflect Lifestyle convictions), and Dreams. The goal is to
recognize a pattern of movement, not that past events necessarily caused present concerns but to
recognize that there may be patterns of behavior possibly originating in childhood, that are
affecting current functioning. Once these Mistaken Beliefs are identified they may then be
corrected and replaced with more useful beliefs which are aligned with the Social Interest.
Adlerian theory or Individual Psychology is a cognitive, psychodynamic, focusing on insight
(not Freudian) perspective containing elements of narrative and systems theories.
Psychopathology develops when one feels discouraged and incapable of completing the
tasks of life which leads to striving toward a position of superiority (Ansbacher & Ansbacher,
1956). Griffith & Powers (2007) described psychopathology by the following quote: “The
discouraged person, operating on the useless side of life under the burden of increased feelings of
inferiority, makes the error of supposing that his or her task is to attain a position of superiority
over others” (p. 99). This does not occur suddenly but rather over time in response to a
perception of being incapable in solving ones problems in a socially interested manner
(Ansbacher & Ansbacher, 1956). There are two planes of significance representing two
directions this striving can move. These are the vertical and horizontal planes of significance.
Adler explained that those who strive on the vertical plane have turned against others and their
goal is to reach a position of superiority over others (Ansbacher & Ansbacher, 1956).
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In contrast, the horizontal plane is the plane of social interest in which an individual
recognizes the demands of living in a socially interested manner seeking perfection over tasks
rather than others (Ansbacher & Ansbacher, 1956). So, people naturally want to better
themselves but do they do it to obtain a position of superiority over others or do they recognize
the demands of communal life and align their goals with the goals of society? We are all socially
embedded, and ultimately all problems are social problems. You will find that those who are
mentally ill strive on the vertical plane and display a lack of Social Interest. However, Adler
believed that no one is completing lacking in Social Interest and they can return toward a socially
useful rather than useless side of life.
Unfortunately our society places too great of an emphasis on individual achievement
which creates a desire for individuals to strive to be better than or greater than others. The notion
of Social Interest determining ones level of mental health is not a widely held belief nor is the
belief that individuals choose everything they do. What would happen if this knowledge was
spread on a mass scale and taken seriously? In a 1929 film from the University of South Carolina
Newsfilm Library Adler explained that all individuals that are against society have one thing in
common which is a lack of Social Interest. Adler (1929) explained “So we find at last that all the
failures in life, problem children, neurotic and psychotic persons, delinquents, suicides,
drunkards, and son are always lacking Social Interest. And it is not only this interest but in the
same way they are also lacking courage, understanding, and the right training for the solutions of
social problems.” Social Interest is more than the act of helping out your neighbor or holding the
door for someone because this is what society expects. Rather, it is a genuine concern which
cannot be faked. If an individual or society does not truly care for others this cannot be hidden
and is reflected by everything we do. This is more than an idea; it is a fundamental cursor of
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mental health that needs to be taken seriously. Our society is a prime example of faking Social
Interest.
Large corporations, the Federal Reserve banking system which reduces American
citizens to a position of slavery, pornography, the idealization of violence, and the condoned rape
of women in the United States Air Force represent just a few examples that reflect a lack of
Social Interest or concern for others in our society. Furthermore, the United States government at
its core is fundamentally flawed as our military enters into other countries without just cause.
The most recent example involves our entry into the Middle East in which wealthy Americans
lied to the American public and created a war to profit from oil and defense contracts.
The construction of military bases in the Middle East and elsewhere in the world reflects
Americas striving for power against Social Interest, towards a position of superiority over others
masked by a facade of caring for others and the goal of spreading democracy. It is not just
corporations and the government who are to blame, all of us could do more to help others. The
United States has become a society of egocentrism and excess as we are responsible for more
waste than any other country. If we (society) do not start caring for others on this planet and the
planet itself, we will perish from the earth.
In terms of mental illness and diagnosis Adler distinguished between neurotic and
psychotic individuals. Griffith & Powers, (2007) stated that the neurotic’s behavior is expressed
with two words;” yes, but” (p.72). Yes, I know what is expected of me but I have this symptom,
disorder, or excuse as to why I’m exempt from completing life tasks Thus, neurotics recognize
the importance of acting in a socially interested manner but have an excuse or exemption from
completing these tasks. The neurotics suffering is real but perhaps they have decided “well if I’m
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going to feel bad I might as well get something out of it.” To ease their suffering they call others
into their service for example, through tears which Adler (1956) described as “water power.”
Powers and Griffith (2007) described the behavior of individuals who display psychotic
behaviors by the word, “no, or the no of psychotic” (Griffith & Powers, 2007, p. 86). They fail to
recognize or merely ignore the demands of life and create a fantasy world which may be easier
for them to live in than reality (Griffith & Powers, 2007). Psychotic individuals have decided
that they do not want to play by the rules of society and so fantasy becomes a way for them to
make up their own rules or guiding fictions from which to live out their lives. These individuals
often do not wish to let others in to their private worlds because they are afraid of anyone who
might criticize or attack the validity of their created realities.
All people create Guiding Fictions which they hold to be truth to guide them through
their interactions with the world; however the behaviors of individuals who experience psychotic
symptoms deviate from those experienced by the person’s culture at large. The reason that
psychotics have chosen to create their own worlds can best be explained in the following quote
from Alfred Adler. According to Adler psychosis “appears to us as the mental suicide of an
individual who does not believe himself adequate to the demands of reality and to his own goals”
(Ansbacher & Ansbacher, 1956, p. 323).
If a person cannot meet the many expectations that society places on them, which are
always increasing, or their own expectations and goals they simply give up or commit a mental
suicide as Adler described. This can be seen as a creative solution taken by an individual who is
in tremendous pain; it’s as if they are saying “reality will not allow me a place in where I can be
significant so I will create my own reality”. This overcompensation leads the individual toward a
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striving to be Godlike as they create their own reality in which they are center of importance
(Ansbacher & Ansbacher, 1956).
Kurt Adler and Psychosis
Alfred Adler’s son, Kurt Adler further elaborated on his father’s theories and in 1979
published an article that described the development of psychosis, specifically of Schizophrenia
from an Adlerian perspective. Adler (1979) provides a historical account of how Schizophrenia
was perceived by the public and later the psychiatric profession. He explained that historically
Schizophrenia was believed to be caused by witchcraft or demonic possession. This contention
is still held by some cultures such as Muslim’s even today who do not agree with western
conceptualizations of mental illness. Adler (1979) also pointed out that organic and genetic
arguments have been strongly believed by the medical and psychiatric community and that when
his father claimed to have successfully treated this population his claims were “derogated”
(p.147). This raises the question of why schizophrenia is no longer regarded as a disorder
treatable by therapy.
Mental Illness and Choice
The notion that mental illness, including psychosis is chosen seems to be a difficult sell
to this day. If therapy is just as or more effective than medication than why is there more
emphasis placed on the latter? The answer of course is obvious, money. Those in the business of
profiting off the sale of prescription medications want to convince people that they are sick and
that they need to take medications for the rest of their lives to alleviate the symptoms of their
sicknesses or in this case mental illnesses.
There is less profit to be made if an individual is responsible for their actions and able to
get better, but is this a fair claim to make? At what point is a person no longer responsible for
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their actions, and when they reach that point whose responsibility does it become? For example,
if a man rides a motorcycle without a helmet crashes and suffers from a severe traumatic brain
injury. Let us also suppose that two years later this same man after much physical and behavioral
therapy starts to recover from his accident and begins displaying depressive symptoms as well as
behavioral disturbances. If this man, prior to the motorcycle accident did not display such
behaviors and was a generally satisfied with his life and who did not experience clinical
depression, is it fair to say that he is now choosing to depress and to anger as Glasser (2000)
would say?
One could argue that he chose to ride the motorcycle and so was a risk taker and that he
chose to take the risk. In Adlerian terms every person has a Lifestyle or a characteristic way of
being in the world and in the context of a brain injury one’s Lifestyle becomes scrambled. The
man in the motorcycle is trying to act out his Style of Life by utilizing the areas of his brain that
aren’t damaged and by interacting with his new environment, which after hospitalization is likely
a group home. Would it make any difference if this man had not worn a helmet and perhaps had
a death wish or the death instinct as Freud might say? If this latter point were the case then the
man chose to accept the consequences of his actions.
By following this logic one could argue that those who want to die or take greater risks
are more likely to receive a TBI. Regardless of which is the case society has decided that it is our
responsibility to provide care for all of these individuals regardless of what they have done to
harm themselves or others. These individuals either made an error in judgment or were victims
of circumstances beyond their control. The point is that it’s difficult to accept a biological,
genetic explanation on one end and on the other 100% free will and choice to explain a person’s
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behavior. After the TBI has been sustained it does not seem fair or possible to hold these
individuals accountable for their actions.
If the higher functions of their brains are damaged the more primitive areas will take
over and the question becomes whether they are still in control of their behaviors. Individual or
(Adlerian) psychology is a form of soft determinism meaning that while past events and genetic
predispositions may affect subsequent behavior an individual has the right to choose their actions
and whether to use mental illness as a solution to the tasks of life (Ansbacher & Ansbacher,
1956). However, the debate of determinism vs. free will is not a new one and to help enrich this
debate an example from the philosophy of religion may be useful.
There is a philosophical argument which claims that if God is omniscient or all-knowing
than free will is an illusion (Slowik, 2006). In laymen’s terms this means that if God knows
everything that has and will ever happen then in what sense our are actions truly free? If the
world is a stage and humans are actors in a play, God set the stage, he wrote the script, and he
has also written everyone’s lines. According to Slowik (2006) since God created humans
knowing that everything they would do before they were even created how could anyone do
anything differently?
The consequence of this line of reasoning is that one can either accept that they have no
control over their destinies or that God does not know everything (Slowik, 2006). However, this
western conceptualization of God who is capable of transcending time, is all knowing, and all
powerful (omnipotent) are characteristics that devout believers are not willing to give up and so
the former must be true, i.e. that God does not know everything. But, this is not an acceptable
answer to believers either (Slowik, 2006).
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In terms of science, the world was created by the big bang in which something was
created out of nothing, an idea that most of us can’t even fathom. From this initial creation in
which matter won out over anti-matter and millions or billions of years later humans evolved
into the species we are today isn’t the argument the same? Are we not the result of an uncaused
cause whether it be God or the universe and if so in what sense are actions truly free if
everything we do is predicated on genetics and previous behavior? Either our behavior is
determined or we have free will; however there is currently insufficient evidence to prove which
is the case and so the most useful option is to believe that we have free will and can choose to do
something or choose not to do something. Even the brain injured man in the above example has a
choice of using the areas of his brain that are still functioning to contribute to society as much as
he is able to. Of course it will be more difficult for him to do so than a person who has not
sustained a brain injury, but to give up hope that one can choose to recover and return to a
socially interested position is unacceptable.
The consequences of accepting a belief in hard determinism are that humans are not
responsible for their actions and could not have lived their lives any differently. Thus in terms of
mental illness a person chooses to solve their problems in a socially useful way or having given
up all hope, chooses to adopt a neurotic or psychotic Lifestyle. How do the terms neurosis and
psychosis fit into a discussion of Axis I and II disorders of the DSM-IV-TR?
According to Adler all psychopathology stems from the same root cause i.e. feelings of
inferiority, as previously mentioned (Ansbacher & Ansbacher, 1956). When individuals feel
inferior this leads to discouragement and can result in the development of a mental illness. The
disorders in the DSM-IV-TR can be thought of as the different manifestations of an underlying
feeling of inferiority. According to Sisk (2010) an Adlerian conceptualization of mental illness
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can be described metaphorically. If mental illness is thought of as a tree the roots represent
underlying feelings of inferiority, the trunk is the Lifestyle and the branches then represent the
DSM-IV-TR based mental illnesses (Sisk, 2010). People may be genetically predisposed toward
a particular mental illness, however that does not guarantee it will develop (this includes
Schizophrenia).
Individuals choose whether consciously or unconsciously to be mentally ill as this is their
best attempt at dealing with life. As mentioned above this represents a view of soft-determinism;
while there may be causal factors such as genetics and neurotransmitters that influence the
development of psychopathology what also matters is what the creative individual makes of their
life experiences. It is also important to note that Adler would say that a person is discouraged
rather than mentally ill. An individual has become discouraged about dealing with life rather
than this person is ill and so they must be labeled and deemed abnormal by terms such as mental
illness. Thus, from an Adlerian perspective GSP and AVPD can be thought of as the creative
solutions or positions taken by discouraged individuals, lacking in Social Interest, to solve the
life tasks. Adler also distinguished between neurotic and psychotic individuals.
Social Phobia and Avoidant Personality Disorder can be described as neurotic disorders
whereas Schizophrenia, for example is a psychotic disorder representing a loss of contact with
reality. However, the distinction between neurotic and psychotic conditions and DSM diagnosis
is not always a clear one. The term borderline in Borderline Personality Disorder initially
referred to an individual who was on the border between neurosis and psychosis
(Schimelpfening, 2011). Another is example is that there are specifiers in the DSM-IV-TR such
as for Major Depressive Disorder (a neurotic disorder) that can be specified with psychotic
features (APA, 2000). Although these disorders both appear to be neurotic conditions are they
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the same or similar as the DSM-IV-TR suggests? The first step in attempting to answer this
question is to look at the history of this debate which began with the DSM III published by the
American Psychiatric Association in 1980.
Comparison of DSM Editions
The DSM III was the first edition of the DSM to include diagnoses of Social Phobia and
Avoidant Personality Disorder (Turner, Beidel, & Townsley, 1992). From the onset of these
additions to the DSM there has been confusion as to whether these disorders could be diagnosed
together. The DSM III stated that Social Phobia could not be diagnosed if Avoidant Personality
Disorder is present (APA, 1980). On the other hand it also stated that when considering a
diagnosis of Avoidant Personality Disorder that Social Phobia may be a complication of AVPD
meaning that they could co-occur (APA, 1980). This represented a contradiction within the same
edition of the DSM.
The subsequent editions of the DSM including the DSM III-R, DSM- IV, and DSM-IVTR have also failed to make a clear distinction between these disorders. The DSM III suggested
that individuals with Social Phobia had a fear in one phobic situation (APA, 1980). Turner,
Beidel, & Townsley, (1992) explained that in the DSM III-R this assertion was revised and
introduced a subtype of Social Phobia, the generalized type, which represented the fear “includes
most social situations” (p.326) However, as the researchers went on to explain it was not made
clear how many situations constituted most situations.
Turner, Beidel, & Townsley (1992) suggested that there were 3 Avoidant Personality
Disorder criteria that overlap with Social Phobia and these criteria were:
1) avoids social or occupational activities that involve significant interpersonal
contact, 2) is reticent in social situations because of fear of saying something
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inappropriate or foolish, or being unable to answer a question, and 3) fears being
embarrassed by blushing, crying, or showing signs of anxiety in front of other people.
(p. 327)
Turner, Beidel, & Townsley (1992) argued that only one additional criterion would be
needed as the DSM-III-R required four criteria to diagnose AVPD. However, these authors did
not provide information about which Social Phobia criteria were related to this overlap.
Unfortunately, the revised DSM-IV-TR by stating that these disorders may actually be the same
the APA (2000) has seemingly thrown its hands up in the air and said “we just don’t know.”
Since this debate has not been resolved by the APA research must show the critical factors
involved in this argument. By presenting the experience of these disorders separately beginning
with GSP followed by AVPD these factors can then be identified.
Social Phobia
According to Comer (2002) anxiety is an evolutionary based natural response of the body
to a real or imagined threat. The difference between fear and anxiety Comer explained, is that
fear involves a response to a clearly identified threat whereas anxiety involves a general sense of
dread that is not necessarily attributed to a specific threat. When this fear becomes distressful,
deviant, dysfunctional, or dangerous to an individual clinical concern may be warranted. These
four levels are known as the 4 D’s of abnormality and are considered with any mental health
diagnosis including Social Phobia (Comer, 2002). Distress refers to whether a particular disorder
is upsetting to the individual and deviance illustrates the degree to which a disorder deviates
from norms of typical behavior based on the population at large (Comer, 2002).
In terms of dysfunction this represents the level a disorder interferes with a person’s day
to day functioning such as a person’s ability to complete daily living tasks (Comer, 2002).
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Finally, the level of danger refers to the extent an individual presents a danger to themselves or
others. Sole cases of Social Phobia are unlikely to present a danger to anyone; however anxiety
disorders are often co morbid with others such as the depressive disorders. The risk of suicide
then as is present in depressive disorder would represent such danger (Comer, 2002). The D’s of
abnormality are useful considerations to be made both for Axis I disorders such as Social Phobia
as well as Axis II disorders such as AVPD. Many perspectives can be taken to explain the
etiology of Social Phobia, two of which are neurochemical and behavioral approaches.
Selective Serotonin Reuptake Inhibitors (SSRI’s) have been demonstrated to be
effective in the treatment of Social Phobia according to Tillfors (2004), however it is not clear
whether it truly has an anxiolytic (anti-anxiety) effect or if it actually increases anxiety.
Specifically, low levels of serotonin are suggested to be present in individuals with Social
Phobia. Tillfors suggested that patients initially treated with such medications may experience
these increases in anxiety before the more long lasting effects of the medications occur.
Dopamine, or the pleasure center of the brain, is also said to be affected in Social Phobia
(Tillfors, 2004). An in depth look at these chemicals are beyond the scope of this literature
review. For a detailed explanation of these neurochemical processes as well as information
regarding genetic and neuroimaging research Tillfors (2004) should be read in its entirety.
From a behavioral perspective both classical and operant conditioning has been suggested
to be involved in the adoption and maintenance of Social Phobia (Tillfors, 2004). In terms of
classical conditioning when a previously neutral stimulus is paired with an unconditional
stimulus it becomes a conditional stimulus (CS) which elicits a conditioned response (CR)
(Miltenberger, 2004). For example, if a person has to give a speech (UCS) and they receive
criticism (aversive or UCR) leading to a feeling of embarrassment (CR) they will when placed in
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a similar situation come to expect criticism and feelings of embarrassment and so have been
classically conditioned (Tillfors, 2004). This fear is then maintained by operant conditioning in
which the individual receives negative reinforcement (the removal of an aversive stimulus) by
avoiding the feared situation.
Tilfors (2004) explained that anxiety is then a signal to the individual that they are in a
situation which may cause them pain (Tillfors, 2004). From an Adlerian perspective anxiety is
used to prevent others from finding out that they are incapable of dealing with situations and
ultimately life (Sperry & Carlson, 1996). While many theories speak of possible causes of Social
Phobia the DSM-IV-TR provides specific diagnostic criteria to distinguish individuals with and
without this disorder.
Social Anxiety Disorder and DSM-IV-TR
According to criteria A of the DSM-IV-TR published by the American Psychological
Association (APA) Social Phobia 300.23 is characterized by: “A marked and persistent fear of
one or more social or performance situations in which the person is exposed to unfamiliar people
or to possible scrutiny by others. The individual fears that he or she will act in a way (or show
anxiety symptoms) that will be humiliating or embarrassing” (APA, 2000, p. 456). This fear
commonly leads to the experience of panic attacks (Criterion B) (APA, 2000).
The DSM-IV-TR describes the features of Social Phobia by the following description:
“Common associated features of Social Phobia include hypersensitivity to criticism, negative
evaluation, or rejection; difficulty being assertive; and low self-esteem or feelings of inferiority”
(APA, 2000, p. 452). While these common features are not included in the diagnostic criteria for
GSP they nonetheless seem to parallel earlier conceptualizations associated with AVPD,
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specifically features of low self-esteem (DSM-III) and a view of the self as inferior (criteria 6 in
DSM-IV-TR) which are included in current AVPD diagnostic criteria (APA, 2000).
In terms of differential diagnosis the DSM-IV-TR makes a distinction between Social
Phobia and Panic Disorder without Agoraphobia by the nature of what is feared (APA, 2000).
Panic Disorder without Agoraphobia involves a fear or concern of experiencing unexpected
panic attacks. Panic attacks can occur in the presence of any disorder including Social Phobia.
However, in Panic Disorder without Agoraphobia the fear is of having future unexpected attacks.
Individuals with this disorder may fear experiencing an attack in public (a social context) but the
fear is not limited to this context. Social Phobia is also differentiated from Obsessive
Compulsive Disorder, Post-Traumatic Stress Disorder, and Specific Phobia which involve a fear
of a specific object such as snakes, (APA, 2000).
A generalized type specifier may be added to a diagnosis of Social Phobia if the fears
include both public performance and most social interactional situations (APA, 2000). It is this
generalized type of Social Phobia (Social Anxiety Disorder) that is suggested to overlap with the
Avoidant Personality Disorder. According to the National Institute of Mental Health, NIMH
(2011) Social Phobia has a 12 month prevalence of 6.8% of adults in the United States.
Prevalence refers to the number of cases of a particular disorder at a given point in time, in
contrast to incidence which refers to the number of new cases in a given period of time such as
the number of new cases in a year. The DSM-IV-TR reports that Social Phobia has a lifetime
prevalence of 3% to 13% (APA, 2000). Lifetime prevalence refers to whether an individual
experiences a particular disorder within their lifetime.
According to the DSM III Social Phobia was “apparently relatively rare” (APA, 1980, p.
228). However, it is now considered the most commonly experienced anxiety disorder (Tillfors,
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21
2004). This claim made by the DSM III indicating that Social Phobia was rare may be related to
how the disorders was distinguished from other anxiety disorders at the time. The DSM III
identified Social Phobia as a phobic disorder distinguishable from anxiety state disorders
(Bogels, et al. (2010). According to Bogels et al. (2010) “the term phobia suggests that
similarities with specific phobia, in which avoidance of a circumscribed object, activity, or
situation is an essential element of the disorder” (p.171).
However, the DSM-IV acknowledged that Social Phobia often included multiple social
fears by adding the name, Social Anxiety Disorder in parentheses when listing Social Phobia
(Bogels et al. , 2010). Bogels et al. (2010) cautions that if the term phobia is used to describe
Social Anxiety disorder this could have the unintended effect of underdiagnosing clients. This
may also have been why DSM-III considered Social Anxiety Disorder to be a rare condition.
Now that the criteria have been changed and more accurately reflect the true experience of the
disorder it is being diagnosed more often.
The categorical system of the DSM-IV-TR does not distinguish between levels of
severity when describing disorders and this has many ramifications. According to Bogels et al.
(2010) research suggests that specifiers for Social Anxiety Disorder do not identify real
differences between disorders and that the subtype distinctions are arbitrary. The generalized
specifier rather than illustrating qualitative differences between subtypes merely reflects the
severity of social anxiety experienced (Bogels, et al. , 2010). A greater number of feared
situations indicate a more severe experience of social anxiety. For the reason Bogels et al. (2010)
suggested that Social Anxiety Disorder may be better described on a continuum based on
severity. Thus, Social Anxiety Disorder may better be expressed in terms of dimensions rather
than categorically.
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22
Ruscio (2010) suggested that social fears are at least 60% prevalent among adults at
some point in their lives. Based on this statistic Ruscio (2010) suggests that a dimensional rather
than categorical classification system be utilized to diagnose individual’s with Social Anxiety
Disorder. A categorical system according to Ruscio does not detect individuals who may be
below the threshold of detection and many of them experience the same impairments as those
who meet the full criteria of Social Anxiety Disorder. A description of AVPD will lead into a
discussion of the critical factors involved in a move from GSP to an experience of AVPD.
Avoidant Personality Disorder and the DSM-IV-TR
The DSM-IV-TR provides criteria for personality disorders in general describing
personality disorders as “an enduring pattern of inner experience and behavior that deviates
markedly from the expectations of the individual’s culture. These disorders are manifested in 2
or more of the following areas: cognition, affectivity, interpersonal functioning, and impulse
control” (APA, 2000, p. 686). The DSM-IV-TR describes Avoidant Personality Disorder 301.82
as: “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” (APA,
2000, p. 718).
According to the DSM-IV-TR Avoidant Personality Disorder has prevalence between
.5% and 1% of the population (APA, 2000). This refers to how many people are affected by
AVPD at any given time. The National Institute of Mental Health (2011) indicates that AVPD
has a 6.8% 12 month prevalence. This means that if in any given 12 month period 6.8% of adults
will experience this disorder. Only adults are affected as personality disorders are not diagnosed
in children. AVPD is characterized by shyness often beginning in childhood. In normal
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23
development this shyness typically abates, however in avoidant personalities it increases (APA,
2000).
In terms of differential diagnosis as previously described Avoidant Personality Disorder
may be similar to Social Phobia. Both disorders are characterized by feelings of inferiority and
an avoidance of social situations due to fears of embarrassment or rejection (APA, 2000). The
difference may be in terms of the language used to describe the experience of these disorders.
The words, marked and persistent fear, are used to describe Social Phobia whereas Avoidant
Personality Disorder is expressed as a pervasive pattern of social inhibition. Pervasiveness is a
word used to describe the course of all personality disorders.
According to Merriam-Webster Online Dictionary (2011) the word, pervade means “to
become diffused throughout every part of.” This seems to distinguish these disorders by
describing the former as persistent, meaning the fear consistently or perhaps increasingly occurs
and the latter as pervasive meaning it affects every or many aspects of a person’s life. The
writings of Sperry (2003) further add to this discussion as to the distinction between these
disorders focusing on the experience of AVPD.
Sperry’s View of Personality Disorders
Sperry (2003) described the history of how Avoidant Personality Disorder came to be
included in the DSM. He explains that it was included in the DSM-III; however at that time it
was believed that the disorder was indistinguishable from other personality disorders such as
Dependent Personality Disorder and Schizotypal Personality Disorder (Sperry, 2003). Today,
however the American Psychiatric Association recognizes that these disorders are distinct.
Schizotypal personalities seem to be content with avoiding social contact whereas avoidant
personalities have a strong desire for this social interaction (APA, 2000). Dependent
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24
personalities according to Sperry (2003) are timid and withdrawn due to a need for attachment in
contrast to Avoidant Personalities who are also timid and withdrawn but for a different reason
which is a fear of rejection.
According to Sperry (2003) a dimensional rather than categorical system of diagnosis for
personality disorders will be incorporated into the DSM-5. The current version DSM-IV-TR uses
a categorical approach in which one either has a disorder or does not. This diagnosis is made
based upon the number of criteria met for a particular disorder. A dimensional approach
challenges this classification system as personality traits are considered a style on one end of a
continuum and disorder on the other (Sperry, 2003).
Sperry (2003) describes five proposed dimensional systems including: “1) a pure
dimensional approach, 2) a prototype matching approach, 3) a clinically derived personality
prototypes approach, 4) a five-factor model approach, 5) and a two-step psychobiological
systems approach” (p.20-21). With the pure dimensional system approach a person can be
identified as having a personality trait, disorder, or to be considered to be prototypic (Sperry,
2003). In this system individuals are rated by being checked off if they meet a particular
criterion. If a client meets one to three criteria they possess a personality trait. Meeting four or
five criteria represents having a personality disorder, and according to Sperry if five to eight
criteria are met the disorder is pervasive. If seven to nine criteria are identified as being present
then the disorder is said to be prototypic (Sperry, 2003). The problem with these criteria is that
they are overlapping. If a client meets the requirement for having a personality disorder they also
may qualify as having a pervasive disorder if five criteria are met. Similarly, if seven criteria are
met the disorder is both pervasive and prototypic. Sperry does not clarify whether these overlap
is intentional and allowed i.e. a person could meet more than one classification simultaneously.
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25
In the current categorical system of diagnosis Avoidant Personality Disorder is
represented by meeting four or more criteria (Sperry, 2003). Sperry explained that a dimensional
system, by contrast allows for personality traits to be identified and rather than being diagnosed
with a personality disorder a person may simply have traits of a particular personality style.
Could this dimensional approach be expanded to include continuums across Axis I and Axis II
disorders such as a spectrum between Social Phobia and Avoidant Personality Disorder? Sperry
would argue against the adoption of this continuum at least for these particular disorders. He
acknowledges the debate as to whether these disorders describe the same phenomena. However,
Sperry concludes that current research suggests that these disorders are distinct though they often
co-occur.
Sperry, (2003) describes personality on a continuum ranging from style on one end and
disorder on the other. This represents a range spanning from normality to abnormality. For
example, an individual may prefer a set routine, in terms of Avoidant Personality Disorder they
exaggerate possible risks of doing something outside of that routine Sperry (2003) explained that
another trait vs. disorder comparison is in terms of style the person is “very discrete and
deliberate in dealing with others” vs. being “unwilling to get involved with people unless certain
of being liked” (p. 61). He also described triggering events that lead to Avoidant Personality
Disorder, behavioral, interpersonal, cognitive, feeling, and attachment styles. Sperry also
identified parental influences, temperament, the Avoidant Personalities self-view, world- view,
and the greatest or optimal DSM-IV-TR criteria in identifying this disorder (Sperry, 2003).
According to Sperry (2003) Avoidant Personality Disorder is triggered by “demands for
close interpersonal and/or social and public appearances” (p.60). Their style behaviorally is shy
and withdrawn, interpersonally these individuals are sensitive to rejection, and cognitively they
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26
are hyper vigilant. Affectively, they are prone to depression when they do not feel total
acceptance by others. They may also experience feelings of depersonalization (Sperry, 2003).
Sperry (2003) described the ultimate DSM criterion for this disorder which is an
avoidance of interpersonal contact in occupational situations. The ultimate criterion according to
Sperry, can be used by clinicians as cause to suspect a particular disorder may be present. What
may be of particular interest to Adlerian’s in terms of etiological considerations is that Sperry
(2003) described the “parental injunction” as “we don’t accept you and probably nobody else
will either” (p.68). This injunction seems to reflect a possible mistaken belief that individuals
with Avoidant personalities share. While a continuum model for personality traits vs. disorders
may be useful in terms of how personality disorders are conceptualized and subsequently treated
it does not solve the debate between Axis I and Axis II disorders. Research conducted by
Chambless, Fydrich, & Rodebaugh (2006) has sought to determine what the distinctions are, if
any between Axis I GSP an Axis II APD.
Distinction between Disorders
Chambless, Fydrich, & Rodebaugh (2006) conducted a study to determine if there is a
distinction between Generalized Social Phobia and Avoidant Personality Disorder. They cite
previous findings that claimed the fear in social situations (Social Phobia) is just one fear that
individuals with Avoidant Personality Disorder experience. “In particular, earlier notions of
AVPD included the description of such patients as being generally fearful and avoidant of novel
situations and repressive of their emotions” (Chambless, Fydrich & Rodebaugh, 2006, p. 16).
Another example of the difference in these disorders is that in Avoidant Personality
Disorder there is a “difficulty in forming intimate relationships” (Chambless, Fydrich, &
Rodebaugh, 2006 p. 8). According to Chambless, Fydrich, & Rodebaugh (2006) this difficulty is
CRITICAL FACTORS
27
not experienced in Social Phobia. Furthermore, AVPD is has been suggested as “a problem of
relating to persons” while “Social Phobia is largely a problem of performing in situations”
(Chambless, Fydrich, & Rodebaugh, 2006, p. 16). These distinctions are highlighted in Table 1
below.
Table 1
Characteristic differences between GSP and AVPD
Generalized Social Phobia
Avoidant Personality Disorder
FEAR IN SOCIAL SITUATIONS
MANY FEARS IN ADDITION TO SOCIAL
SITUATIONS
NOT CHARACTERIZED BY HAVING A
DIFFICULTY IN FORMING INTIMATE
DIFFICULTY IN FORMING INTIMATE
RELATIONSHIPS
RELATIONSHIPS
A PROBLEM OF PERFORMING IN
A PROBLEM OF RELATING TO PERSONS
SITUATIONS
One Disorder on a Spectrum
In the current study Chambless, Fydrich, & Rodebaugh (2006) compared participants
diagnosed with GSP who also experienced AVPD. They hypothesized that participants with comorbid GSP and AVPD experienced more severe Social Phobia compared to those with a sole
diagnosis of AVPD. These diagnoses were based on SCID or structured clinical interview for the
DSM-III-R. The sample consisted of 55 participants, 34 female of which were female and 21
male.
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28
In terms of age the participants ranged from 20 to 60 years old with ethnicities of 73%
Caucasian, 22% African American, and 5% Asian or Latino. Thirty six of the 55 participants or
65% experienced co morbid Social Phobia and Avoidant Personality Disorder. A limitation of
this study was that there was not a group with a sole diagnosis of AVPD. Perhaps this is due to
the fact that there really is no such group in existence, i.e. AVPD may not exist without Social
Phobia (Chambless, Fydrich, & Rodebaugh, 2006).Participants were measured by self-report
questionnaires, and role play measures. A one-way ANOVA of the self-report questionnaires
confirmed the researcher’s hypothesis that participants with co-morbid GSP and Avoidant
Personality Disorder reported significantly higher levels of social phobia compared those
diagnosed with only GSP. For this test the significance was “[F(1,53)=8.16, P=.006]”
(Chambless, Fydrich, & Rodebaugh, 2006 p. 13).
The researchers report that the effect size was close to large for this test. Role-Play
measures were used to determine the participant’s level of social skills by opposite sex
confederates and were based on the Social Performance Rating Scale. Chambless, Fydrich, &
Rodebaugh (2006) hypothesized that subjects diagnosed with AVPD would have poorer social
skills than subjects diagnosed with GSP alone. The results showed that the participants with co
morbid GSP and AVPD experienced higher levels of anxiety and negative thoughts compared to
those with a sole diagnosis of GSP but this result though close was not statistically significant
“[F(4,33)=2.32; n2=0.21;P=.08]” (Chambless, Fydrich, & Rodebaugh, p. 14).
From the results of these tests and others such as cluster analyses not reported in this
literature review they concluded that “Thus, overall, regardless of the methodological approach
used, the most parsimonious conclusion to be drawn from these data is that AVPD, at least as
defined by the DSM, should be considered a severe form of GSP rather than a separate
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29
diagnosis” (Chambless, Fydrich, & Rodebaugh, p. 16). They do acknowledge this point,
however that due to a small sample size this can only be concluded for this particular group of
participants (Chambless, Fydrich, & Rodebaugh, 2006). Other studies have demonstrated that
subjects with AVDP differ on levels of depression.
According to Huppert, Strunk, Ledley, Davidson, & Foa (2008) individuals with co
morbid GSP and AVPD experienced higher levels of depression and more severe social phobia
on self-report measures at an alpha level of p<.05. Another study by Turner, Beidel, & Townsley
(1992) concluded that the subjects in their study differed in only one area, depression.
Individuals with co morbid GSP and AVPD had higher scores on the Beck Depression Inventory
than those with GSP alone “M=70.4 vs. M=59.3, p<.05” (Turner, Beidel, & Townsley, 1992, p.
392). The results of these studies show that similar findings have been found across studies.
These studies simply scratch the surface of the available research on the spectrum debate of GSP
and AVPD and taken alone cannot claim to resolve this debate. They do however; provide
statistically significant findings elucidating which critical factors may be involved in a move
from GSP to an experience of AVPD.
Critical Factors and Discussion
A critical factor that leads an individual from an experience of GSP to AVPD is the
severity of their symptoms. Individuals with co morbid GSP and AVPD experience more severe
Social Phobia than those with GSP alone. They also experience more severe depression and fear
a greater number of situations. This has lead researchers to conclude that AVPD is an extreme
form of GSP. Furthermore, according to Griffith, Powers, & Sperry (2006) the antidepressant
medication Effexor has been shown to be effective in treating APD traits; however these authors
do not indicate the degree of effectiveness.
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30
Since antidepressants are used to treat GSP this would suggest that these conditions are
the same since they are effective in treating both conditions. Griffith, Powers, & Sperry (2006)
suggest that the only difference in these disorders is quantitative which supports the contention
that AVPD is merely an extreme form of GSP. Based on current DSM-IV-TR criteria it seems
that these disorders cannot sufficiently be distinguished from each other and that they fall on a
spectrum with AVPD on the severe end. However, there has also been disagreement as to
whether the DSM-IV-TR criteria represent the true experiences of GSP and AVPD (Chambless,
Fydrich, & Rodebaugh, 2006).
Specifically, it has been argued that a core feature of AVPD, low levels of self-esteem,
was removed DSM-III criteria and is not included in current DSM-IV-TR criteria (Chambless,
Fydrich, & Rodebaugh, 2006). However, according to the DSM-IV-TR low self-esteem is
currently also characteristic of GSP as described in the common associated features of Social
Phobia (APA, 2000, p. 452). If low self-esteem is associated with both disorders this
characteristic may present a complication in distinguishing them. Secondly, another core
difference between GSP and AVPD may be that individuals with GSP have difficulty performing
in social situations while those with AVPD experience difficulty in forming intimate
relationships (Chambless, Fydrich, & Rodebaugh, 2006).
Five of the seven criteria for AVPD seem to overlap with Social Phobia. These criteria
are 1, 2, 4, 6, and 7, whereas only two criteria, 3) “shows restraint within intimate relationships
because of the fear of being shamed or ridiculed” and 5) “is inhibited in new interpersonal
situations because of feelings of inadequacy” appear to reflect a difficulty in forming intimate
relationships (APA, 2000, p. 295). For a complete description of the diagnostic criteria please
refer to the DSM-IV-TR.
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31
The characteristic of having difficulty in forming intimate relationships seems to provide
a clear core distinction between these disorders as it separates their true essences. Based on this
argument these disorders are indeed distinct. However, for the past 32 years since the publication
of the DSM III in 1980 to the present DSM-IV-TR released in 2000 the American Psychiatric
Association has failed to make this distinction. A meta-analysis and review of the available
research on this topic must be completed by the DSM V Task Force to ensure that this debate is
resolved before the publication of the DSM V. In order for clinician’s to provide accurate
diagnoses of their client’s symptoms the diagnostic criteria must be changed sufficiently to
distinguish between these disorders.
Arguments for a Dimensional Shift in DSM Diagnosis
Before an argument can be made supporting the adoption of a model of diagnosis a
description of the purpose of diagnostic assessment must first be explained. According to
Kamphuis & Noordhof (2009) the DSM has 3 main goals which are: “1) developing international
concepts of psychopathology, 2) make expert decisions on whether a disorder is present or not,
and 3) make decisions about treatment” (p. 294). The current version of the DSM uses a
categorical system of diagnosis in which one either has a disorder or does not. This is determined
by narrowly defined criteria which are then counted and if a person meets an arbitrary cutoff
score then they are diagnosed with a particular disorder.
While there are many criticisms of this current model there are benefits to such a system.
For example, Kamphuis & Noordof (2009) explained that clinicians argue that communication is
easier, that is in comparison to the alternative system of dimension. Furthermore, if the DSM-5
were to keep the categorical system this would ensure continuity during this transition between
editions. This claim seems to suggest that there are certain individuals who do not like the idea of
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32
change and are subscribing to the philosophy of “if it ain’t broke don’t fix it” or perhaps “well,
this is the way we’ve always done things.” The problem with such a position is that the system is
flawed and empirical research supports the adoption of a dimensional model. Dimensional
models have greater statistical power, reliability, and can be made to meet the needs of
diagnostic assessment (Kamphuis & Noordhof, 2009).
Bernstein (2011) described the progression of the DSM from the DSM-III released in
1980 to the current DSM-IV-TR revision to set up an argument for DSM-5 to shift towards a
new classification system. According to Bernstein (2011) the DSM-III was the first DSM edition
to operationalize diagnostic criteria. Due to an increase in the prescription of psychotropic
medications there also became a need to have greater inter-rater reliability between clinicians
and researchers. Reliability refers to the degree to which a psychometric test measures similar or
consistent results across measurements. Conversely inter-rater reliability refers to whether
different clinicians or researchers are finding similar results using the same tests (Bernstein,
2011).
In contrast validity refers to whether an assessment truly measures what its purported to
measure. Bernstein (2011) explained that the DSM diagnoses have been “reified” meaning that
they are described as if they exist in reality. This is due to the push for mental illnesses to be
conceptualized and diagnosed as it is done in the medical field. Cancer actually exists in reality
but does a DSM diagnosis? It seems that we might be cleaving to concepts that do not actually
exist. Due to the high rates of co-morbidity between diagnoses and the not otherwise specified
catch all diagnoses there is great concern that these disorders may not be reflect clients true
experiences (Bernstein, 2011). The increase in reliability according to Bernstein (2011) has come
at the cost of validity and the solution is to move towards a new classification system. In this
CRITICAL FACTORS
33
same vein the DSM, according to Clercq, Fruyt, Leeuwen, and Mervielde (2006) the DSM has
failed to explain the connection between traits found in childhood with adulthood personality
disorders. Clercq et al. (2006) proposed that “a specific child maladaptive trait taxonomy further
offers a useful framework to incorporate a developmental perspective in the construction of the
DSM-5” (p. 639). This argument is beyond the scope of this review and should be read in its
entirety. However, it provides another example of how the APA seeks to hold onto an arbitrary
separation between Axis I and Axis II disorders, a separation that is contradicted by research.
This system, a quantitative dimensional approach, rather than categorical
conceptualization of mental illness should be applied not only to personality disorders but to
Axis I disorders as well. However, Bernstein (2011) explained that this will likely not happen by
the time the DSM V in 2013. She explained that the DSM-5 will be a working document which
can be added to as new research and conceptualizations become available. The question becomes
how often the DSM-5 will be updated to reflect these changes. With our societies progression
towards reading texts on electronic devices such as book readers perhaps physical paper texts
will become obsolete.
If the DSM V will be constantly revised this change may be necessary and clinicians
could simply download updated versions of the DSM based on the most up to date research. This
proposed shift for the entire DSM to move towards a dimensional model is described by
Bernstein (2011) as the process of meta-structure. By combining or clustering current DSM
diagnoses these cluster factors can be tested against each other. This could revolutionize the way
mental illness is conceptualized and diagnosed and may solve the problems of overlap between
disorders (Bernstein, 2011).
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34
According to Krueger and Eaton (2010) personality disorders were placed on a separate
axis (II) so that clinicians would consider client’s personality characteristics in addition to any
Axis I clinical diagnoses. This is an interesting point because it shows that the distinction
between axes was not due to fundamental differences between clinical conditions and personality
disorders, but rather that this separation is arbitrary. Krueger and Eaton (2010) also point out that
while personality traits can be listed on Axis II there is no system for how to classify these traits
other than by referencing 1 of the 10 DSM-IV-TR personality classifications. According to
Krueger and Eaton (2007) explain that there is no evidence that “the latent structure of
personality is best characterized by 10 categorical entities” (p. S66). The concept of latent
structure of personality refers to the state of particular personality characteristics lying dormant
in a person or that they are present but not readily visible.
In terms of the DSM-IV-TR based categorical diagnosis Krueger & Eaton (2010) are
suggesting that these 10 types do not sufficiently distinguish one person’s personality from
another’s. For this reason a new system is needed and Krueger & Eaton (2010) explain that DSM
V investigators have described a new model of personality, the pathological five model or PFM.
The PFM extrapolates from the empirically significant 5 factor model of personality which can
be recalled by used the pneumonic device OCEAN. These five factors include: openness to
experience, conscientiousness, extraversion, agreeableness, and neuroticism (Krueger & Eaton,
2010).
In the DSM-IV-TR categorical system of diagnosis a person either meets the criteria for a
disorder or they do not. When a personality disorder is diagnosed within this system cutoffs are
used, for example 5 of 9 criteria must be met to receive a particular personality disorder
diagnosis (Krueger & Eaton, 2010). The problem is that this cutoff is arbitrary and not based on
CRITICAL FACTORS
35
clinical data but rather because 5 is more than half of 9. The authors go on to claim that more
consideration to personality traits must be added to the DSM V (Krueger & Eaton, 2010).
Krueger and Eaton (2007)
Three years prior to this article Krueger et al. (2007) argued that personality disorder
research shows that dimensional and categorical implementations of diagnosis are needed.
Furthermore he claimed that “implementation will likely be more successful if it is an orderly
and logical progression from the DSM-IV-TR” (p. S 65) If research does indeed confirm the
need for such a system Krueger’s point seems obvious. However, he seems to be pointing out
that the APA, who is responsible for making such changes shouldn’t try to completely reinvent
the wheel with the DSM-5 revision. Rather the transition should be made as smoothly as possible
as this is a new way of doing things. Acceptance by clinicians will be more likely if they can see
that a change to a categorical/dimensional system will build on or add to the diagnostic process.
Kruger et al. (2007) pointed out that clinicians like the current prototype system because
there are 79 diagnostic criteria across the 10 available personality disorder diagnoses. Therefore,
if clinicians are to accept a new dimensional system they need to see that it will be easier, more
accurate, and time efficient, etc… However, one could also argue that they will have no choice
as the DSM is the most widely used an accepted diagnostic manual for mental disorders other
than the International Classification of Diseases, (ICD).
Personality Disorders and DSM-V
According to the American Psychiatric Association (2012) the DSM-5 is scheduled to be
released in May of 2013 and the most current proposed revisions of how personality disorders
will be conceptualized is now available. The DSM-5's definition of personality disorders in
general will also change and there will be a combination categorical-dimensional hybrid system
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36
of diagnosis for PD's (APA, 2012). The essential features of a personality disorder in DSM-5 are
defined as: “impairments in personality (self and interpersonal) functioning and the presence of
pathological personality traits” (APA, 2012). The continuum of self includes the areas of self
and identity and continuum of interpersonal includes empathy and intimacy. Each of these
dimensions is measured on a five point scale from 0 to 4 (APA, 2012).
The DSM-5 diagnosis of personality disorders will include a determination of whether
impairments in personality are present or not and whether one of the specific subtypes of
personality disorder are present or not (APA, 2012). The general diagnostic criteria of
personality disorders for DSM-5 which has been significantly revised from the previous DSMIV-TR edition will correlate with the new dimensional system (APA, 2012). Unlike the DSMIV-TR the general characteristics for all personality disorders will aid clinicians in their
diagnoses when the presence or absence of impaired personality traits is determined. By contrast
the DSM-IV-TR’s general diagnostic criteria were not used when diagnosing clients are were not
based on empirical evidence (APA, 2012).
Three of the PD types, Schizoid, Dependent, and Histrionic will be removed; however
the APA (2012) has not offered an explanation as to why these disorders will not be included in
the DSM-5. The DSM-IV-TR indicated that individuals who do not meet enough criteria to be
diagnosed with one of the 10 specific types, but who display traits of more than one personality
disorders should receive a diagnosis of Personality Disorder not otherwise specified (NOS). The
fact that Personality Disorder NOS is the most common diagnosed personality disorder reflects
the fact that change is needed (APA, 2012). One such change will include the removal of the
NOS specifier for personality disorders (APA, 2012).
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37
The NOS specifier will be removed as it does not provide clinical utility in terms of
distinguishing one client diagnosed with Personality Disorder NOS from another (APA, 2012). If
a client is not diagnosed with one of the six types they will be diagnosed with Personality
Disorder Trait Specified (PDTS) measured by the Levels of Personality Functioning Scale. The
PDTS scale will replace the NOS specifier and is an improvement because unlike the NOS
specifier the PDTS designation will reveal quantitative differences between others diagnosed
with PDTS (APA, 2012).
Avoidant Personality Disorder and DSM V
As previously mentioned DSM-5’s general diagnostic criteria for personality disorders
will involve the identification of impairments of personality functioning in both self and
interpersonal areas (APA, 2012). These areas are specifically defined by each disorder including
AVPD. Additionally, there have been significant changes made to the specific diagnostic criteria
for the Avoidant Personality Disorder type. The DSM-IV-TR indicates that 4 or more criteria
must be met to diagnosis AVPD, however according to the APA (2012) the DSM-5 proposes that
in order to diagnose AVPD “the following criteria must be met.”
By not designating a cutoff score of how many criteria must be met this suggests that all
criteria will need to be met to diagnose AVPD. Features of low self-esteem have been added
back to the DSM-5 criteria after being removed during the revision from DSM-III-R to DSM-IV.
This feature has been added under identity functioning and combined with DSM-IV-TR criteria,
the new criteria states “low self-esteem associated with self-appraisal as socially inept,
personally unappealing, or inferior, excessive feelings of shame or inadequacy” (APA, 2012).
Features of low self-esteem have been considered by researchers as a characteristic
distinguishable from SAD and adding it back to the criteria for AVPD increases the chances for
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sufficiently separating the two disorders. A second impairment in personality functioning under
the heading self-functioning includes self-direction which involves a person’s capacity to take
risks and pursue goals (APA, 2012). Interpersonal functioning is described by impairments in
empathy and intimacy. According to the APA (2012) impairments in empathy include:
“preoccupation with, and sensitivity to, criticism or rejection, associated with distorted inference
of others perspectives as negative.”
In addition to impairment in personality AVPD criteria also includes the presence of
pathological personality traits in the domains of detachment and anxiousness (APA, 2012).
Detachment includes 3 facets which are withdrawal, intimacy avoidance, and anhedonia.
Withdrawal involves “reticence in social situations; avoidance of social contacts and activity;
lack of initiation of social contact.” What the criteria do not explain is the reason individuals
with AVPD engage in these behaviors. The empathy and intimacy impairments described above
suggest that these individuals are reticent in social situations. In terms of the empathy
impairment individuals are preoccupied with criticism and rejection and perceive others as
negative but why? On the other hand the intimacy impairment indicates that individuals with
AVPD will not get involved with others unless there is a certainty that they will be liked due to
fears of shame and ridicule. This criterion at least gives a reason, but it is unclear if this reason
also applies to the withdrawal criterion as well. According to the APA (2012) intimacy
avoidance involves “avoidance of close or romantic relationships, interpersonal attachments, and
intimate sexual relationships” and again there is not reasoning given for this.
Anhedonia is the 3rd and final pathological personality trait included under detachment
criteria and involves a “lack of enjoyment from, engagement in, or energy for life’s experiences;
deficits in the capacity to feel pleasure or take interest in things” (APA, 2012). Anhedonia or
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lack of interest in activities that were previously enjoyable is a symptom of depression, an Axis I
condition and represents over-lap between Axis I and Axis II. If the person never experienced
any joy perhaps a distinction could be made, however it is hard to believe that a person’s life has
been completely without joy. A description of the changes in Social Anxiety Disorder criteria
will add to this debate, followed by a discussion of whether the changes between SAD and
AVPD will distinguish between these disorders.
Social Anxiety Disorder and the DSM V
There have been several proposed revisions made by the American Psychiatric
Association DSM-5 (2012) for how Social Anxiety Disorder (SAD) will be both conceptualized
and diagnosed. It is important to note that these proposed revisions do not represent the final
draft of the DSM-5; however they may be utilized speculatively as the most recent available
information about where the conceptualization of this disorder is headed. In previous DSM
editions including the most recent edition of the DSM-IV-TR this disorder is listed as Social
Phobia (Social Anxiety Disorder). However, in the DSM-5 this will be reversed and the disorder
will be listed as Social Anxiety Disorder (Social Phobia) (APA, 2012). The rationale behind this
change is to avoid confusion between Social Anxiety Disorder and Specific Phobia. According to
the APA (2012) criterion A has been changed by removing the word persistent and describing
“marked fear or anxiety.” These terms (marked fear and anxiety) will be used to describe all
anxiety disorders including SAD as research suggests they are core features all anxiety disorders
(APA, 2012).
Three types of social interactions have been identified by the new DSM-5 criteria and
include: interaction, observation, and performance (APA, 2012). The addition of these 3
identified types of situations may eliminate the ambiguity in DSM-IV-TR criteria describing a
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fear in most social situations by specifically outlining which types of situations are typically
feared. Additionally, the DSM V will not include a generalized specifier for SAD. In the DSMIV-TR the phrase show anxiety symptoms was placed in brackets in criterion A and these
brackets will be removed by the DSM-5 as they are a core feature of all anxiety disorders.
Additionally the terms humiliating and embarrassing will be placed in brackets as examples of
the broader term negative evaluation because this term more accurately describes this core fear
in SAD. This phrase will also be moved from criterion A to Criterion B in the DSM-5 (APA,
2012).
Criterion B in the DSM-5 describes a fear of showing anxiety symptoms in front of
others and in other cultures the reason for this fear may be different (APA, 2012). To account for
this difference the DSM-5 acknowledges this difference in the SAD criteria by adding the phrase
or will offend others to criterion B. Another proposed revision is to increase the number of
diagnostic criteria for SAD from eight to 10. Specifiers for SAD will also change, starting with
the removal of the generalized type specifier and the addition of a performance only specifier
which is defined by a restricted fear of performance situations only (APA, 2012). The removal of
the generalized specifier type superficially resolves the debate as to whether Generalized Social
Anxiety Disorder and Avoidant Personality Disorder are the same or similar disorders since it
will no longer be an available diagnosis. However, further discussion is needed to determine
whether the DSM-5 will sufficiently reconcile the debate. Another specifier, selective mutism
will also be added to the SAD criteria.
An individual with selective mutism is unable to speak in situations where speaking is
expected but they are able to speak in other situations (APA, 2012). Selective mutism has
previously been listed in the DSM as a separate disorder, however research has suggested that
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due to the high co-morbidity found between this disorder and SAD that selective mutism is a
potential manifestation of SAD. For this reason selective mutism will no longer be an available
as a separate diagnosis.
DSM-IV-TR criterion F indicates that the symptoms of SAD must be present for at least
6 months for individuals less than 18 years of age (APA, 2000). The DSM-5 proposes that the
age restriction be removed (APA, 2012). Due to this change all individual that experience
symptoms of SAD will not qualify for diagnosis of the disorder until these symptoms are present
for at least 6 months, regardless of age (APA, 2012). Since social anxiety is a relatively common
phenomenon it is important that this duration criterion be present so that transient social anxiety
is not misdiagnosed as SAD.
The term transient according to Merriam Webster (2012) refers to the quality of passing
especially quickly into and out of existence. In terms of SAD this means that social anxiety may
manifest itself and then quickly abate, and so a hasty diagnosis is not warranted. Criterion C
from the DSM-IV-TR which states that “the person recognizes that the fear is excessive or
unreasonable” will also be removed (APA, 2012). It has been determined that clients are not
good at judging whether their fears are excessive are unreasonable, instead clinician’s will now
make this determination (APA, 2012).
Does DSM V end the Continuum Debate?
According to the DSM-IV-TR “there appears to be a great deal of overlap between
Avoidant Personality Disorder and Social Phobia, Generalized Type, so much so that they may
be alternative conceptualizations of the same or similar disorders.” Since the publication of the
DSM III there have been contradictory explanations of how to interpret the experience of these
orders, whether they can coexist, or if they are distinct. Due to the fact that the DSM is currently
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a categorical system of diagnosis clinicians must be able to provide clear distinctions between
these disorders and up until this point it has failed to do so. This review of the literature has
sought to determine whether these disorders are indeed distinct and the answer to the
consequences of this determination go beyond theoretical debate as they have implications on
clinical practice.
The DSM-5’s proposed revisions to the diagnostic criteria for Social Anxiety Disorder
(SAD) and Avoidant Personality Disorder (AVPD) will end this debate on at least one level, i.e.
the removal of the generalized specifier for SAD. It was this specific type of SAD that was said
to overlap with AVPD. The DSM-5 will add two new specifiers to its criteria which are selective
mutism and performance only subtypes. The core feature of SAD is a fear of displaying anxiety
symptoms in front of others and a fear of one or more social situations in which one may be
scrutinized by others.
Three types of social situations have been identified by DSM-5 criteria and these are:
interaction, observation, and performance situations. This distinguishes SAD from AVPD by
focusing attention on the core experience of the disorder which is a fear of scrutiny in
performance situations. By contrast the core features of AVPD include a fear of interpersonal
relationships and feelings of low self-esteem. Low self-esteem has been argued to be a core
feature of AVPD, however it was removed from the DSM after the DSM-III-R. Fortunately,
features of low self-esteem will be included in the DSM-5 criteria.
Clinical Implications
The Diagnostic and Statistical Manual of Mental Disorders (DSM), originally published
in 1956 has sought to create a reference guide that would be useful to clinicians and researchers
to describe the psychopathologies observed in practice. By seeking agreement about the
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experience of these identified disorders the best course of action can then be administered.
Subsequent additions of the DSM have attempted to objectify psychology and validate it as a
legitimate science comparable to the medical model. The DSM up through the current DSM-IVTR uses a categorical classification system of diagnosis in which one either meets the criteria for
a mental health diagnosis or they don’t.
This system is flawed as there is considerable overlap between disorders through comorbidity and the overuse of the not otherwise specified diagnosis. This overlap reflects a
fundamental flaw in the system, which is that people do not fit neatly into prescribed categories
and each individual’s experiences are unique. The categorical system attempts to mirror the
medical model by identifying these specific criteria or symptoms as if the disorders exist in
reality. The problem with this reasoning is that mental illness is fundamentally different than
medical illness in that the disorders described by the DSM-IV-TR are based on theories of latent
structure meant to be used as a guide and are not entities that exist in reality.
The primary focus of this literature review was to describe the overlap between
Generalized Social Anxiety Disorder and Avoidant Personality Disorder. However, in the grand
scheme of things it is merely an example of a flawed system and one must ask themselves, why
do I even need to care if there is a difference between these disorders? This is a valid question
and the answer is because if you work in the mental health field, there are many reasons. For
example, the DSM-IV-TR is the most widely accepted diagnostic reference guide currently in
use other than the International Classification of Diseases and if we (clinicians, researchers, etc.)
must use this system than it had better be accurate. The key words in the previous sentence are
reference guide, the manual is a tool to aid clinicians in understanding their clients behaviors.
However, this is not the only reason the DSM-IV-TR is used, it is also used to receive insurance
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44
reimbursements, research money, and to feed the money machine that profits from the sale of
psychotropic medications.
Consider for a moment the process that an Adlerian therapist would take in diagnosing a
client and furthermore let’s assume that this therapist only accepts out of pocket payments, i.e.
they do not accept insurance. Treatment in the Adlerian model is the same regardless of who the
client is or what their symptoms are and diagnosis is not reached from looking in a reference
guide. While in Adler’s time this may have been common practice today some might consider
this blasphemous as the DSM is the bible and you better believe in it. Diagnosis in Adlerian
therapy involves a Lifestyle Assessment, which includes an analysis of a client’s family of
origin, early recollections, dreams, and birth order.
From this assessment which is collaboratively undertaken with the client, the client’s
beliefs about self and the world can be elucidated. This leads to insight in which the client learns
how their Lifestyle impacts their lives and the choices they make in the pursuit of their goals.
From this awareness clients can then choose to hold onto beliefs that are useful and change those
that are not. Now imagine that you’re a clinician and you’ve received a referral from a colleague
who has been diagnosed or labeled with Borderline Personality Disorder. A diagnosis has
already been made, likely by a psychiatrist who even though personality disorders can’t be
treated with medications, but guess what? She takes medications because if an Axis II disorder is
present there must be an Axis I so we can get her to take meds for that one.
Since you don’t have to worry about diagnosing your new client one of the next things
you might think of is how you will treat this person and likely the first thing that pops into your
mind is DBT because its known as the gold standard for treating borderline clients. If you’re an
Adlerian or even a cognitive behavioral therapist who is not specifically trained in DBT then you
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might not even agree to see this client because the help they need is beyond your level of
competency. However, perhaps the organization you work for says you don’t have a choice and
must see this client. The first thing you can do is throw the DSM out the window because it’s not
going to prepare you for how difficult that client is going to be from the moment you meet him
or her until the moment therapy terminates.
The DSM-IV-TR does not offer much help in the way of treatment advice; instead it
gives you labels to put on someone so that insurance companies will pay for them to receive
therapy, beyond that you don’t need it. This of course is an extreme position which no one would
ascribe to but its absurdity takes away some this great emphasis that is placed on diagnosis.
Clinician’s need to be able to accurately diagnose clients and the current system does not allow
for this. The problem is that clients don’t fit into neat little categories or types that are distinct
from each other and so if clinicians are made to use a reference guide than it should be made to
more accurately reflect and describe the experiences of clients.
The DSM-5 task force has begun this process with the adoption of a hybrid
categorical/dimensional model of personality functioning, however they are currently unwilling
to expand this model to Axis I disorders. They (the APA) are cleaving to the traditional
categorical system of diagnosis even though many of the same problems exist on Axis I such as
high levels of co-morbidity between disorders and the NOS specifier. Furthermore, there exists a
contention that Axis II personality disorders are fundamentally different from Axis I disorders
and this is the justification used for why the DSM-5 will use the new categorical/dimensional
hybrid model for personality disorder diagnosis only.
Let’s say that a client was diagnosed with Major Depressive Disorder at the early age of
6 and this disorder persists throughout the rest of their lives. The DSM terminology would
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describe this Axis I condition as persistent, however personality disorders are described as
pervasive. Couldn’t a depressive disorder that persisted throughout a client’s entire life have
been described as pervasive? Pervasiveness refers to the quality of affecting every area of a
person’s life and depression definitely affects all areas of life.
One could argue that a depressive isn’t always in a depressive episode and can experience
“normal” periods of functioning. However, the same argument could be made for a borderline,
which is that borderlines experience symptoms of transient anger and psychotic episodes but
these do not occur all of the time. From another perspective the question could be posed, “how
could it hurt?” If a dimensional component were added to Axis I disorders all were really saying
is to quantifiably reflect severity. The DSM-IV-TR attempts to describe severity categorically by
distinguishing conditions such as Dysthymia and Major Depressive Disorder, for example.
Dysthymia describes a patient with less severe depression and so one either has moderate
depression (dysthymia) or severe depression (Major Depressive Disorder). Conversely this can
be seen in the distinction between Bipolar I and Bipolar II.
Specifiers are also used to describe mild, moderate, severe, and chronic types of Axis I
disorders but don’t tell you how much numerically. The current system does also not allow for a
conceptualization of functioning to be considered as normality on one end and psychopathology
on the other as Sperry (2003) suggested. If a client’s mental health is measured and describe their
functioning as normal than they cannot receive treatment, at least not through 3rd party
reimbursement. The consequence of this is that clinicians must look for pathology. The
distinction made between Axis I and Axis II disorders seems to be arbitrary and does not account
for problems of co-morbidity, between or within axes. By adding a dimensional component to
the diagnosis of Axis II personality disorders the DSM-5 has made a step in the right direction.
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However, it seems that the addition of a dimensional conceptualization of Axis I disorders would
be greatly beneficial.
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