Avoidant Personality Disorder and Social Phobia. Studies of Personality Pathology and Functioning, Childhood Experiences and Adult Attachment
Year: 2016
Type: dissertation
Study design: Observational Study
Abstract: Background: Avoidant Personality Disorder (AvPD) and Social Phobia (SP) are closely related and common disorders both in the community and in clinical settings. Whether the two disorders represent different severity levels of social anxiety disorder is currently in dispute. The relationship between AvPD and SP is probably more complex than previously assumed. Little is known about similarities and differences in personality functioning and psychopathology, temperamental and environmental factors, and the underlying processes related to social discomfort in subjects with AvPD and/or SP, such as attachment styles. We wanted to use the Experiences in Close Relationships (ECR) inventory to assess attachment style; however, the Norwegian version of ECR has previously not been tested in a sample of patients with personality disorders (PDs).\nObjectives: This thesis aimed to explore differences and similarities in developmental and psychopathological aspects of AvPD and SP through comparison of symptoms, personality pathology and functioning, temperament, childhood experiences/trauma, and attachment styles in patients with AvPD and SP. In this way, we hope to contribute to a more thorough understanding of the psychopathology of AvPD and the relationship between the two disorders. By investigating the psychometric properties of the Norwegian version of ECR in a sample of PDs, we were able to use this instrument to compare attachment styles in AvPD and SP.\nMaterials and methods: Papers I, II, and IV are based on a sample of 91 adult patients with AvPD and/or SP who participated in a multi-site, cross-sectional study. In paper I, we compared three diagnostic groups: one group of patients who had SP and not AvPD; a group who had AvPD and not SP; and a group of patients who had both diagnoses. In papers II and IV, we merged all of the patients with AvPD into one AvPD group with and without concurrent SP and compared them to patients with SP without AvPD, designated as the SP group. Ninety percent of patients in the SP group had generalized SP. Patients were examined using diagnostic interviews and self-report measures, including the Index of Self-Esteem, Severity Indices of Personality Problems, Adult Temperament Questionnaire, Childhood Trauma Questionnaire, Parental Bonding Instrument, and the ECR inventory. In paper III, we examined the psychometric properties of ECR and its two short-forms, ECR-S and ECR-N12, in a sample of 495 patients with PDs. Analyses of the internal consistency, as well as confirmatory and exploratory factor analyses, were conducted.\nResults: Papers I, II, and IV – Compared with the SP group, patients with AvPD had more symptom disorders and met more criteria for other PDs. They reported more psychosocial problems and more personality dysfunction regarding self-esteem, identity, and relational problems. AvPD predicted personality dysfunction in the identity and relational domains over and above the presence of SP, number of other symptom disorders, and other PDs.\nBoth AvPD and SP were associated with negative childhood experiences. Patients with AvPD reported more severe childhood neglect, most pronounced for physical neglect, compared to patients with SP without AvPD. The difference between the disorders in neglect remained significant after controlling for temperamental differences and concurrent physical, sexual, and emotional abuse. Both SP and AvPD were associated with high levels of attachment anxiety and avoidance, and a large majority of patients in both groups had an insecure attachment style. Patients with AvPD had higher levels of attachment anxiety than patients with SP without AvPD, especially regarding the subfactors “Anxiety for abandonment” and “Separation frustration.” Severity of AvPD was associated with “Anxiety for abandonment” over and above concurrent SP, the number of other symptom disorders, and criteria met for other PDs. The diagnostic groups did not differ significantly in levels of attachment avoidance.\nPaper III – The internal consistency of ECR was found to be questionable. Confirmatory factor analyses revealed poor model fit for the two factor solution of ECR and ECR-S. The two factor solution of ECR-N12 revealed mediocre fit, indicating a potential for improvement. An exploratory factor analysis indicated five factors representing two somewhat different aspects of attachment avoidance and three aspects of attachment anxiety. This alternative five factor solution was called ECR-FF.\nConclusions: Papers I, II, and IV – The results indicate that AvPD involves broader and more severe areas of personality pathology and dysfunction than SP, supporting the conceptualization of AvPD as a PD. Furthermore, childhood neglect could be a risk factor for AvPD and SP, most pronounced for AvPD, and may be one contributing factor to phenomenological differences between AvPD and SP. AvPD seems to be associated with more attachment anxiety than SP. Thus, fear of abandonment may play a significant role in avoidant personality pathology. Paper III – Inferences from scale scores based on ECR should be derived with care in samples with PDs. A revision of ECR and ECR-N12 is warranted, and further studies are needed to investigate the validity of ECR-FF among different clinical samples.
Language: English
Subfield: Clinical Psychology
Field: Psychology
Domain: Social Sciences
Open Access status: green
OpenAlex ID: W2376454072