The Essential Guide to Overcoming Avoidant Personality Disorder

CHAPTER 2

Counterphobic Avoidants

I divide avoidants into two broad classes of individuals: Type I, typical, classical avoidants; and Type II, atypical, counterphobic avoidants.

TYPE 1: TYPICAL, CLASSICAL AVOIDANTS

These avoidants, discussed in detail in the last chapter, display the classical Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) profile of pervasive shyness and fearful isolation. Within this class, variations of severity exist on a continuum. Some of these individuals live by themselves or with their family, either staying at home and not socializing at all, or socializing only with a few selected individuals, attempting to meet people but having difficulty connecting as they try, but fail, to form sustained and sustaining relationships. Others form relationships that are only partially avoidant: limited in degree or of reduced intensity such as bicoastal marriages; serial monogamous relationships; or relationships that are stably unstable, dysfunctional because being with unattainable partners makes the relationships unlikely to come to fruition, or if they do, sooner or later, they are destined to dissolve.

TYPE II: ATYPICAL OR COUNTERPHOBIC AVOIDANTS

Type II avoidants do relate, but their relationships take the form of isolating social rituals. The Psychodynamic Diagnostic Manual describes such individuals collectively under the heading “Converse Manifestation: Counterphobic Personality Disorders”: individuals who are “psychologically organized around defenses against their fears.” These avoidants handle relational anxiety through “denial [and] reaction formation,” that is, by using the characteristic pathological defense of “I can face anything without fear.”¹ There are three subtypes, Ila, Ilb, and Ilc, which I now describe in some detail.

Type IIa

Type IIa avoidants characteristically display avoidance Sullivan describes as consisting of isolative social rituals. He calls these “pseudosocial ritual[s],” where individuals are “busily engaged with people, but nothing particularly personal transpires.”²

Coleman seems to be referring to individuals with isolating social rituals when he describes a kind of relationship discord consisting of numerous love relationships that are often short-lived, and generally intense and unfulfilling, in one of the following ways: compulsive cruising and multiple partners, where cruising is ritualistic and trance inducing; compulsive fixation on an unattainable (or deficient) partner; compulsive multiple love relationships; and compulsive sexual behavior in a relationship (sometimes associated with compulsive autoerotism).³

In the realm of selecting unattainable people to relate to, these avoidants pick distant, remote people who are already taken to convince themselves that they are attempting to relate but failing to do so for reasons not fully under their control. Their cry “it won’t work” is consciously or unconsciously part of their original plan to make certain that when it comes to their relationships, much goes on, but little actually happens.

A Case Example

A woman picked a married man to be her lover, then, when he “threatened” to become available, discouraged him from divorcing his wife—first by dissociating (not hearing his thoughts about marriage or, hearing them, passing them off as an aberration of the moment, not to be taken seriously) and second by becoming personally just remote enough to create sufficient doubt in the man’s mind to make him hesitate to take the final step. All along, she suspected that this man being a proven cheat on account of his record with her made him unlikely to be a suitable candidate for marriage.

On his part, the man, to ease his guilt about having an affair, selected this woman in the first place, suspecting that her need to have an affair with a married man meant that it was likely that she would lose interest in him should he actually “threaten” to get a divorce and propose marriage. He sensed that she would be intolerant of real intimacy because of her need to be “the interloper,” in her case, part of what he saw as her pattern of an all-too-apparent fear of success.

The man’s wife knew that her husband was cheating on her from evidence that would have convinced even the most trusting and innocent of people that he was being unfaithful. But because she, being an avoidant herself, unconsciously needed to permit and encourage the affair, she failed to spot the obvious, and even (when she could no longer fool herself ) refrained from confronting him and having a showdown, thus giving the affair her imprimatur: by being complicit in its neglect.

Many Type IIa avoidants are what I call “mingles” avoidants: individuals whose fear of closeness and commitment is either sufficiently mild or under adequate control to permit significant forays into relationships that are, however, tenuous because they are easily fractured, often by minor insignificant stress. Clara Thompson, describing such individuals, states, “Problems of intimacy are among the most disturbing interpersonal difficulties. . . . There are detached people who are not particularly hostile, who live as onlookers to life. They have an impersonal warmth so long as no closeness is involved, but they fear any entanglement of their emotions. . . . Many of these people get along very well in more superficial relationships. In fact, they may be the ‘life of the party’ or ‘the hail fellow well met’ so long as no permanent warmth or friendliness is demanded.”⁴

Some typical Type IIa “mingles” avoidants look hypomanic due to their tendency to quell relational fears by making numerous but superficial “devil-may-care” contacts. They become serial daters or serial monogamists who meet new people/partners easily but have difficulty sustaining and developing the ensuing relationships so that quality becomes a casualty of quantity as they keep others, often many at one time, at bay through a gun-notching hyperrelatedness that covers an underlying remoteness and isolative tendency, which together create the self-fulfilling prophecy that “I can’t meet anyone substantial and so am doomed to remain alone for the rest of my life.” Typically, never seeming to be able to settle down, they become overly active in the singles scene. They frantically socialize looking for a mate, only to jump from one situation that does not work to another that works just as badly, continuing that pattern in spite of its obvious frivolity and ultimate futility. They juggle many ongoing but resolutely superficial relationships within a chic and sophisticated lifestyle that fills their days with insignificant others who function for them as self-esteem enhancers: mere hood ornaments, pretty girls or handsome men on the arm, worn like a badge that says, “View me favorably because if I can get something this stunning, I must be someone special myself.” When rejected, hypomanic Type Ila avoidants make an especially frantic attempt to feel loved once again. They rush about looking for new lovers, grabbing the first accepting person who comes along, not for any winning quality that person might have, but to get unrejected, to undo a sense of despair and a feeling of emptiness, as they become too much the life of the party in order to deny the feeling that they have been disinvited from the ball.

A Case Example

A man put ads on the Internet just to see how many hits he would get, only he then did not reply to the people who wrote to him, or, what was worse, replied, in essence, “I’m a young, virile guy longing to meet you, rich and famous, and I’m sure we can get along because you sound just right for me, but I’m so busy now that I just can’t take the time to meet someone as wonderful as you seem to be, but I will get back to you as soon as I can, but meanwhile feel free to meet other men, though I hope you will wait, because I will call, if only you will be patient.” Although he consciously feared he would never have a partner, he nevertheless once abruptly arose in the middle of a date with a new, rather exciting, adoring woman to leave for home because he couldn’t wait to download a new love song from the Internet. Another time, under similar circumstances, he abandoned a woman to go home to check to see if he had left his sound equipment on—thinking he was afraid it would overheat and he wouldn’t be able to play soft, soothing music during subsequent sexual encounters. Still another time, under similar circumstances and for the same reasons, he left to check to see if he had scratched and ruined a CD by playing it on a damaged machine.

In the singles bars he attended he played Berne’s game of “Kiss Off” or “Buzz off, Buster.”⁵ He dressed to look sexy, stood in alluring poses, and gave others come-hither looks, only at the first sign that others were interested in him he removed himself, becoming aloof and disdainful even though he was the one who had first extended an invitation. In ongoing relationships he said, “We must get together again sometime,” but he never made the next date, or, making one, broke it, reassuring the victim that this was the very last time it would happen, just so that he could make it happen again. In his sexual behavior premature withdrawal was the order of the day—not to prevent conception, but to first tempt and excite then to frustrate by starting just so that he could stop short and avoid fulfilling the woman completely.

Many such men and women form these pseudorelationships based on a fascination with other peoples’ superficial qualities so that they pick others according to such surface attributes as their looks or possessions, substituting impersonal for personal relationships by relating to attributes rather than to people. Still others relate, but to an anonymous, collective “them,” as did the avoidant who was active with his fan club to avoid having relationships with any one personal fan. Notable for many are a lack of affectional reciprocity: they give affection when it is unlikely to be returned, but withhold it should it appear to be forthcoming.

Unlike Type I, shy avoidants, who are neophobes—that is, individuals who cannot initiate relationships because they fear the new as something unknown—Type Ila “mingles” avoidants are neophiles who want to, can, and like to attend social functions and initiate relationships once there. Only they have to move on because they long for the challenges involved in meeting someone new. Becoming restless and impulsive in familiar situations and feeling contemptuous of present company, they grab at the latest, newest thing. Underneath, many fear success due to a masochistic need to suffer that makes it difficult for them to accept being happy and fulfilled. When these avoidants say, “This relationship is wrong for me,” they really mean that it is wrong: because it is too right.

Many of these avoidants join groups of other avoidants with the same or similar problems. Now they all head together for, but never seem to find, a conquest. All concerned roam in “packs,” hoping to “snare a man” or “get a woman into bed.” Instead, all they relate to is the collective, with each group member making certain that the other members don’t bolt, while simultaneously maintaining group cohesion by ostracizing outsiders from their magic inner circle. Often heavy drinking and drug usage are part of the picture and can even become the main purpose of the group, the group’s real, or even only, “social” activity.

Not all type IIa avoidants with isolating social rituals actually get to the point of burning through relationship after relationship. Some, instead, compulsively plan for, but never actually proceed with, a seduction, as did the individual who decorated and redecorated his apartment so that “women will yield when they see my beautiful place,” only to never actually invite women up to visit, and developed an all-consuming and all-surpassing desire to be “where it’s at, with the in crowd,” at “in” resorts, rubbing elbows with “celebrities, not lowlifes” in the trendy bar or restaurant that only special people know about, a place “where you can really meet women,” although during all the years I treated him, he rarely went to such places, and when he did, he never once even attempted to say hello back to the many women who, clearly interested, came over to say hello to him.

Type IIb

Type IIb, or seven-year itch, avoidants seem able to form more or less full and satisfactory relationships, but only for a time. Unlike Type Ila avoidants, who have difficulty relating/committing fully right from the start, they at least seem to relate well/commit fully in the beginning. But all the while, they are planning their escape. Not atypical is the patient who, after a three-year engagement, seemingly without warning announced that he was taking a hiatus from the relationship and would call again after the few months’ time he said he needed to work things out in his mind. A year later, he had become a bitter, lonely man, who still hadn’t made the promised contact.

Many of these avoidants are typical “dumpers,” who opt out by precipitously rejecting an innocent and unprepared victim, spurting out something like, “I want some down time to think,” “I need a break,” “I want to be free,” “I met someone new and fell in love, so I want a divorce,” or saying nothing, just disappearing forever out of a formerly significant other’s life—even when, or just because, the relationship seems to be working. They leave their innocent victims feeling mystified and hurt, thinking “I didn’t do anything to deserve this,” especially because when they go, they typically cite their partners’ defects exclusively, while whitewashing their own limitations entirely.

A Case Example

A personal friend, a dental school student, called me up once or twice a day to unload his serious emotional problems on me. After several months of this, he suddenly stopped calling. Concerned, I called him up to ask him what was wrong. To my question, he replied, “I can no longer speak to you. I just got an important sensitive academic position and I cannot even let on that I know you. You know much too much about me for that.”

Type Ilb avoidants are often narcissistic individuals who typically leave after using people up, dumping others precisely when they seem to want something from them in return. Often they actively provoke their partners to get annoyed with them so that they can have the excuse they need to abandon them. This way, they can look more like the victim than the victimizer. A husband wants to go out drinking with the boys, but his wife disapproves. He has no trouble antagonizing her by picking on her for small things like vacuuming when he is trying to watch television. She gets defensive, saying, “Who else is going to clean around here?” and now he has the reason he needs to stomp out: he is a poor, henpecked husband, undeservedly married to a harpy.

Type IIb avoidant adolescents characteristically have a history of having dumped their parents without warning. Many elope, saying they did it to break free from long-resented parental domination—but the domination is more fantasized than real because they are acting on fearful fantasies of being controlled that are, in reality, the product of their own avoidant transference toward their parents.

A Case Example

My daughter Carley was a girl all set to go to nursing school. The hospital where she worked was going to pay 80 percent of her tuition if she promised to work for them for three years afterward, and she had so wanted to be in the medical field for years that she even used to go to the medical school cafeteria dressed in surgical scrubs to pretend she was a doctor (weird, but no weirder than the crush she developed on her dermatologist, whom she used to follow around with a girlfriend, who was also in love with him). So what does she do to avoid the responsibility of developing herself and a career, as I had hoped? She runs off with a schizophrenic stalker who believes the president of the United States is going to send him to Iceland to develop an energy formula, cuts off everyone in her family who can give her a reality check, drops all of her former friends, and immerses herself in his crazy family where she can live in the land of the blind as the one-eyed queen. She has basically reinvented her life from scratch, embracing everything she used to hate about her former life (she used to hate it when I had relatives over, referring to them as “hellatives,” but she is now entrenched in a numerous-clan family); and then she would never go to church, even when her religious school required it, but now she goes every Sunday because her husband’s parents are religious fanatics. She marries after only knowing her husband-to-be for a short period of time—and this after she told me she is part of an age where it is considered wiser to live with someone first. She then rushes to have a baby to lock herself into her predicament so that she can avoid having to go back to who and what she used to be. Cutting off her entire old personal history and roots was her way to avoid taking responsibility for her life by escaping into a totally new fantasy world, where nothing is expected of you in terms of developing yourself and working at a career, and all that is now demanded of you is to be physically present for your husband.

Type IIc

Type IIc avoidants remove themselves from others via a process of reaction formation, where they distance from all by becoming overly involved with, or actually immersed in, a regressive relationship with one. This type is exemplified by the codependent individuals described by Melody Beattie,⁶ some of whom are avoidants who move away from home and in with a steady partner or spouse to become immersion junkies, who seem nonavoidant because they are in a close, all-encompassing, loving permanent relationship with one person, but are, however, not relating to one out of love, but hiding out from all out of fear as well as out of anger that leads them to show their dislike of, and try to defeat, all the other people in their lives.

Sometimes these bosom relationships work, and last, but if the number of books written on how to overcome codependency is any indication, all is not well in the codependent life. For codependent relationships are often not as loving as they seem to be; rather, they can be unhealthy hostile-dependent relationships that, though they often last, less often really work.

Other Type IIc avoidants stay too close to their parents, living at home with no partner or spouse, as did the man who worked at home from his computer as a stock trader and had few or no friends, didn’t go out on dates, and watched pornography all day long on the Internet. Then, after years of refusing to marry a woman because he didn’t want to hurt his mother, he finally acquiesced—but he never told his mother, or the rest of the family, that he had done so, and instead, to the full detriment of his marriage, hid his wife from all concerned and continued to live at home and otherwise act as if he were single, hoping to avoid disappointing his mother, just so that he could keep from causing her to get sick over him.

CHAPTER 3

Healthy and Normal versus Pathological Avoidance

HEALTHY AVOIDANCE

Avoidance can be healthy when it is, as Sullivan suggests, a conjunctive force used to “enhance security.”¹ Healthy avoidance can also consist of a rational philosophical desire to be alone. As such, it is preferential, that is, something individuals have reasonably decided is both good and good for them and so have comfortably built into their lives—a splendid self-sufficient self-containment that allows them to achieve their desire to remain independent of others, be their own masters, and enjoy the peace that comes from removal and detachment. For such avoidants, the song that refers to jangling spurs that say that you should roll merrily along, being glad that you are single, is apropos. For these are independent souls who aver that relationships, and particularly marriage, are not right for them because they want to come and go as they please, because for them, being “me” does actually require “being free.”

Some Case Examples

One such avoidant would regularly and comfortably eat dinner in a restaurant all by herself reading the Sunday newspaper on Saturday night and go walking alone by the seashore day in and day out. Most of all, she liked closing her eyes and putting hot compresses over them; having a few drinks at home alone; rocking by herself on her porch in her favorite rocking chair; self-hypnotizing by submitting to the drowsy nirvana- and sleep-inducing drone of the lulling train or car ride; being soothed by monotonous ragas; and performing repetitive activities like crocheting or knitting. She also relished reading escape literature that took her away to the cold North or out West to the lone prairie, where she fantasized riding a horse by herself under the stars. If she suffered at all, it was not from her isolation, but from the social pressures that made her feel guilty about being as isolated as she really wanted to be. She wanted to eat, live, and play alone, but a critical world, and an uncomprehending therapist, made her ashamed of feeling that way, although that was what she wanted and exactly what seemed right for her as an individual.

A married writer felt, “I would like to retreat from the world, line my room with cork like Proust, and write, write, write, alone, all day long.” Then he did essentially just that: he purchased a house trailer, which he parked in the driveway of his home, and worked there “to avoid having my family disturb my concentration.” Eventually, he moved from California to New York, leaving his wife and children behind, commuting but only on occasional weekends. He acted not out of a pathological fear of closeness, but out of a desire for separateness—in the belief, later proved correct, that distance would lend enchantment both to his work and to his relationship with his wife, who, “fortunately” being an avoidant herself, was even more comfortable than he was with the arrangement.

A middle-aged patient had a job working as a blackjack dealer in Las Vegas gaming halls. One day, she had an epiphany. Tired of “stealing money from drunks,” she instead decided to buy and go live by herself on five acres of land in northern Arizona. Her land was a piece of desert without water or electricity, two miles from her nearest neighbor, a place whose extreme remoteness she called “the main advantage of living in the wild.” With her own hands, she built a log cabin out of limbs she cut from the trees in her backyard. She now hauls her water from 30 miles away in her Chevy truck, uses solar panels to make electricity, and heats her home with other logs cut from the trees around her house. She never gets bored because “she has to work too hard for that,” and she loves her existence because daily she reminds herself that life is all about not what she has, but what she has left over to give to others.

Avoidance is also healthy when it is a limited, small-scale, creative, distancing maneuver appropriate to specific circumstances or for the ultimately greater nonavoidant good of providing a welcome escape from a tumultuous world too much with one: a world full of uncomfortable, unimportant, but upsetting relationships likely to spread to contaminate, undermine, or destroy what potentially more meaningful social and personal contacts remain. Such avoidance as a useful method for dealing with stressful external situations is a justifiable self-protective reactive response that wards off properly anticipated or actual humiliation or rejection at the hands of the inconsiderate or hurtful others that come into everyone’s life, such as the intrusive, backbiting professional colleague or the undesirable, overly aggressive personal suitor. Potential lovers should at least consider avoiding partners who do not reciprocate and offer love back, and we all should at least consider avoiding people who torture us by nagging us, hurt us by being prejudiced against us, or threaten to harm us, if not physically, then emotionally, by reviving old, unmanageable traumatic interpersonal agony or by suddenly rejecting (dumping) us. Nor is there any sense in being a hero with wild, potentially dangerous paranoids, having a fight that wins points but costs lives. In short, there are many self-help books out there on how to get along with difficult people. What many avoidants need is a self-help book on how to get along out there without them.

Avoidance is also healthy when it is a defense that provides a welcome resolution of or escape from reactive inner turmoil. It is healthy to want to escape from one’s own sadistic impulses by avoiding wild kingdom animal shows that rub one’s nose in the laws of the jungle, and even to want to avoid facing sexual desires that provoke guilt— staying away from X-rated movies less for the moral reasons generally cited and more because the close-up anatomical view revives uninte-grated/unmanageable primal-scene experiences or activates quiescent prior traumatic sexual molestations. A particularly bright side of the defense of obsessive-compulsive avoidant procrastination is pause thus allowing time to think. That permits internal conflicts and difficult real life situations to be resolved implicitly, and in the longer run by simply waiting for the tincture of time to kick in.

NORMAL AVOIDANCE

Avoidance that is not entirely healthy can still, under certain circumstances, be within normal limits. For example, avoidance is within normal limits when, as part of grief, it permits the individual to be alone with his or her nostalgia, with his or her faded clippings and reminiscences, dwelling on a pleasurable past to deny an intolerable present, indulging in a better-days, if-only fantasy. One patient, after the death of his wife, retreated into arranging and rearranging his old photos and the sympathy cards he got when his wife died, doing so in order to keep alive her memory to avoid suffering the pain associated with having to live his life without her. He also stayed alone in the large house they once occupied together just so that he could continue to be surrounded by the pleasant memories there, even though the house was too large for his needs, too difficult for him to keep up, and in the suburbs, although all his activities were in the city. And at a shore house they once shared, he kept and nurtured all his wife’s plantings, even though, or in a sense just because, the yard, although it was becoming overgrown and wild, still remained in its “original” state.

However, a continuum exists between normal and pathological grief, with pathological grief becoming avoidance when it is excessive, overly intense, continuous, and prolonged, as in the following case.

A Case Example

A patient informed me, “One of my friends made his first million right out of college writing some kind of innovative software, so he retired and followed his dream to sing folk songs with his guitar. He got a gig at a famous restaurant and bar. Later on he married, then divorced, but apparently he still loved his ex-wife. Then she died a few years after the divorce. Now he had to stop singing because he would unpredictably start crying at the thought of her death. When he wrote to me to express his condolences about my own wife’s death, he told me all of this and how he now lives out in the woods somewhere, like a hermit, telecommutes for an advertising company, and has for his only ‘friends’ the business cable channel, which he leaves on all day. He never leaves his home, and never will, according to him. And the tears still come, unexpectedly.”

Avoidance can also be within normal limits when it is part of the normal developmental process, for example, part of “adolescent turmoil,” where adolescent rebellion has the beneficial purpose of paving the way for the child to grow up and become an adult who, having turned into a more independent man or woman, can now leave home without second thoughts and free of guilty regrets.

Avoidance is also normal when it is a rational reflexive response to a difficult partner. Is this the case here? (And who in the following exchange is avoiding whom?)

A Case Example

I recently got the following letter:

Can you please direct me (well, my husband) to someone in or

near Fargo, ND who might be able to help him. He has avoidant

personality disorder and has “ended our relationship” countless

times. I am not only heartbroken each time, but am at my wit’s

end, and his doctor has recently referred him to a social worker who specializes in women’s addictions of all things. I just don’t know where to turn, as I love this man dearly and don’t know how to get him the help he needs, and I don’t know how I can cope with this, short of ending the relationship which I really don’t want to do.

I replied that I wished I could help but I didn’t know of anyone in her area. She shot back in what I thought might be a somewhat passive-aggressive fashion, as follows:

Dear Dr. Kantor. Thank you for answering my email. I am not very hopeful for my husband finding the help that he needs in this town.

Was she expressing anger toward me—for being less than helpful—in the form of disappointment? At any rate, I felt bad, and wished I were somewhere else. Was I being highly attuned to her unspoken anger, or was I just being hypersensitive out of my sense of guilt?

Avoidance is also normal when it is an interim, transitional, planned part of psychotherapy. In fact, therapy well done works partly by temporarily enhancing avoidance—by offering the avoidant not only a sanctuary from everyday cares, but also a time out where he or she can temporarily stop, take stock, retreat, and reconsider life options and goals: becoming more avoidant for now, in preparation for becoming less avoidant in the future.

AVOIDANT PERSONALITY DISORDER

The following section attempts to clear up what appears to be widespread confusion about the differences between avoidant personality traits and the full avoidant personality disorder (AvPD) syndrome as well as about comorbidity, where AvPD coexists with one or more di-agnosable Axis II disorders, resulting in a mixed personality disorder. (Comorbidity is discussed at length in chapter 7.)

Personality Traits

In this book, although I do not always spell it out, many of my discussions of AvPD are in fact discussions of avoidance; that is, they are not about AvPD, but about the individual traits that together go into making up the AvPD. These traits by themselves do not constitute the personality disorder, which consists of a cluster of personality traits.

Personality traits are primary behaviors, the product of rigid, armored attitudes that are in turn set ways of viewing things, coming from within, weakly and only with effort influenced from without: overly rigid, fixed, repetitive, predictable, and often inappropriate responses barely subject to the dictates of reality and common sense. Traits resemble overvalued ideas—preoccupying beliefs, close to convictions, that lie somewhere on the continuum between rational beliefs and irrational delusions. An example of an overvalued idea is emotionally based, rigid, inflexible, unvarying, and off-the-mark ideology from the politically far Left or far Right. Some traits, like excessive worry, are ego-dystonic, that is, they feel like unwanted foreign bodies in the mind, while others, like withdrawal, can be ego-syntonic, that is, they feel acceptable, desirable, and enjoyable.

Dynamically, traits originate in developmental fixation or regression; are products of learning and experience; can be the result of identification with others with similar or the same traits; constitute the behavioral manifestations of active defenses; can be the product of an unpredictable (sometimes overly lax and sometimes overly harsh) superego or conscience structure; and can represent the lingering legacy of early, unintegrated trauma.

Generally speaking, traits may be either adaptive, as the trait of ambitious competitiveness can be, or maladaptive, as are the traits of lack of self-assurance and masochistic self-destructiveness. Personality traits are not inherently either normal or pathological. This is so because legitimate individual personality differences exist, with some people normally more introverted than others, and such different personalities as uncomplicated Type A and Type B personalities both within the normal range. Also, in determining the presence of normalcy versus psychopathology, external circumstances have to be taken into account. Thus a trait that is pathological under some cultural and environmental circumstances is nonpathological under others, for example, on vacation or at a special time of the year, with such terms as winter doldrums reminding us that we as individuals, and society as a whole, often make cultural allowances for some deviation from year-round norms.

Personality Disorder

In exceptional cases, a personality disorder can consist of the use of one favored trait employed either only under certain circumstances or continuously. The former is exemplified by dissociation that only occurs in the face of “acceptance emergencies,” or “projection” that only occurs under extreme stress and is meant to create a resolutely “not-me” excuse to avoid feeling guilty about one’s unacceptable thoughts and actions. Generally, however, a personality disorder is made up of multiple traits. These tend to be selected on the basis of affinity with each other, for example, shyness and submission or withholding and withdrawing. Also, unless the traits selected are inherently distinctive, and, if multiple, combined in a unique way, personality style, not personality disorder, will result. In the realm of “inherently distinctive,” the traits that constitute a personality disorder are generally abrasive and pungent, with negative traits favored over positive traits, so that Mr. Lowdown predominates over Mr. Loveable and maladaptive traits are favored over adaptive traits. In the realm of “combined in a unique way,” unless there is a critical mass of traits that additionally syner-gistically distort the personality, we will not have a personality disorder, but a pattern less dramatic in presentation, startling in nature, and devastating in effect than a true syndrome needs to be. Put another way, unless the resulting psychological construct makes waves, ruffles feathers (one’s own and others), and attracts psychiatric attention because the individual, for any one of a number of reasons, develops difficulties that are sufficiently overt to be obvious, and sufficiently intense to become noticeable, that is, unless there are discrete, obvious, and generally troublesome interpersonal/social behavioral consequences, the diagnosis of a personality “style” or “type,” rather than a “personality disorder,” should be considered.

In the realm of comorbidity, many, if not most, avoidants do not exhibit avoidant personality traits or disorder alone. AvPD is commonly not diagnosed by itself; rather, AvPD is often part of a complex syndrome characterized by more than one personality disorder, the elusive “pure singular syndrome” rarely ruling in a given individual. In great measure, this is because the individual component traits of AvPD are not distinctive enough to suggest only one diagnosis so that, for example, the trait of withdrawal can also be schizoid or phobic, leading the diagnostician to call the withdrawn individual a “mixed avoidant/schizoid” or to say that he or she is suffering from a personality disorder “best described as avoidance due to a social phobia generalizing.” Like many personality disorders, AvPD is a somewhat elusive entity due to being made up of traits that are in themselves undistinguished and assembled into a tentative and shifting psychological edifice, rough in outline and construction, that is less a firm unvarying entity than a proclivity to move in a certain direction, in this case, anxious withdrawal, as distinct, for example, from suspicious remoteness.

Conversely, only a few personality disorders have a relatively hard-edged identity: the obsessive-compulsive and the paranoid representing two exceptions.

A caveat is that a personality disordered label cannot be attached to an individual unless an experienced clinician has seen the patient in person, carefully studied him or her over a significant period of time, and determined if overall behavior, not just one or two examples of it taken out of, or even in, context, warrants that such a determination be made.

CHAPTER 4 Sexual Avoidance

There are two broad categories of sexual avoidance: innate or essential (asexuality) and acquired (anxious).

DESCRIPTION

Innate or Essential Sexual Avoidance (Asexuality)

Innate or essential sexual avoidants suffer from a sexual hypoactiv-ity disorder, a kind of “sexual alexithymia” where the individual experiences diminished or absent sexual urges and believes that that state of affairs is normal, welcome, desirable, and acceptable. The cry is, “I don’t feel sexual, I don’t want to feel sexual, I just can’t have sex, I won’t have sex, who needs sex, sex is not for me.” Some asexual men and women complain only of a lack of desire, while others also complain of a lack of genital sensation. Some once felt sexual but lost that feeling later in life. Others claim that they had nothing to lose because they never had strong sexual feelings in the first place. Some retain the capacity for romance. Others are as personally unromantic as they are sexually unarousable.

A Case Example

One of my asexual patients half-jokingly said that he was “perfectly happy being in love with his truck.” He cracked that he was so in love with her that he had fallen in love with her “head over wheels.” He spoke of how sad he was to have to let his truck go now that he bought a newer, younger girl, for his truck was a faithful companion, but getting on in years. She had 315,000 miles on her and had been with him for a decade. If he sold her, he couldn’t get much money for her because of all her mileage. But the person who bought her would be getting a great little woman because she was still in very good shape and in a position to serve. True, not all of her anatomy was still intact, but anything anyone needed was still there, and she could still do everything important she needed to do, and do it as well as any girl half her age.

This man had had sex with his wife a few times in the beginning of their marriage. After they produced a child, he started thinking that sex was evil, so to get away from his wife’s sexual advances, he built her a separate house attached to the main dwelling so that they could live together, yet apart, and go their separate ways: she to France to have a series of affairs, and he to his job, driving his beloved truck by day and even sleeping in her at night.

On those rare occasions when his wife still approached him for sex, he would tell her in essence, “We did it already—we had a kid; why do we have to do it again?” He would then make the following excuses as he went off to sleep by himself:

• I can’t sleep with you in the same bed; you snore and toss and turn.

• You don’t keep yourself up.

• You are too old.

• I am too old.

• It’s the same thing over and over again.

• The kid will overhear us.

• Every time I do it, I get irritated down there.

In passing, he also noted that not only his sexuality, but also all his biological functions were slow—so slow, indeed, that he only had a bowel movement once a week. Then he added that anyway, for companionship, he was content with his 20 cats, each of which had a special personality, which he would then go on to describe in detail as if he were talking about 20 parts of a wife, split among 20 different souls. This one purred when he stroked her, that one slept with him, this one kissed him good night, that one woke him up in the morning, this one gave him the feeling that he was wanted, and so on.

Both he and his wife agreed to keep their one son at home as much and as long as possible. They even homeschooled him as part of their plan to groom him to be as interpersonally avoidant as his father was sexually avoidant: a day trader in the market, working from his home computer, able to support himself adequately without ever having to leave the house—and Daddy.

My patient loved his life, and he loved his wife, but he never missed nor complained about not having sex with her. Nor did he have relations with other women. He was not homosexual either. As he put it, “I am simply content to go about my business from the waist up, without having to attend to each and every one of my body parts from the waist down.”

He never sought nor felt he needed treatment. Originally, he had come to see me because his wife had asked him to go for a consultation “just to see if something is wrong and if so what could be done about it.” But, uninterested in continuing therapy beyond our initial meeting, he made another appointment, then cancelled it and never returned.

His wife dealt with her own strong sexual needs by having a series of affairs. Though he knew about them, he didn’t really seem to mind. He did not deny that she was being unfaithful to him. What bothered him most was the possibility that she would meet someone new and leave him, then not be around to help him bring up their son and take care of the cats. He even agreed to pay for her trips to France, though he knew that she went there to actually meet and have sex with men she had initially contacted through the Internet. He figured “that a man should pay his wife’s transportation, and since she didn’t have her own car it is only fair that I pay for a plane trip to France now and then.” He would do anything for her—but one—as the price of her staying with him. Her reassurances that she sought only affairs, not divorce, were enough to keep him calm and happy.

This man claimed that he no longer felt any sexual feelings. He denied that he was suppressing them out of a sense of guilt originating in psychological conflict, social teachings, or religious tenets. His asex-uality only bothered him when someone he perceived to be knowledgeable and in authority told him that something was wrong and that he was missing something, or when he started worrying that his wife would leave him for sex and that he would grow old and alone. For him, asexuality was not pathology, but philosophy. And because his wife accepted him as he was, the pairing worked, the marriage lasted, and both he and his wife claimed to be happy and well adjusted just the way things were.

Acquired Sexual Avoidance

While true asexuality is innate or essential, acquired sexual avoidance, what Fenichel calls “psychogenic sexual impotence,”¹ is the product of inhibition arising out of conflict. This psychogenic sexual impotence is often the product of an erotophobia, or “love phobia.” This becomes manifest in various ways, including guilty hesitancy about doing anything at all sexual, resulting in transient or prolonged fearful celibacy; limiting oneself to substitute gratifications such as hobbies used to partially or fully divert oneself from getting sexually involved; sexual coldness and frostiness; a paradoxical, counterphobic hypersexuality; or physical sexual symptoms such as diminished genital sensation, erectile dysfunction/impotence (inability to get or maintain an erection), premature or retarded ejaculation in the man, and dyspareunia or vaginismus in the woman.

Erotophobia is itself the product of a constellation of underlying fearful components. Some erotophobes fear touching and being touched because they view anything sexual as dirty and disgusting—as did the patient who feared shaking my hand because of the possibility that I would contaminate him with a sexually transmitted disease. Others fear that their sexual feelings will flood them so that for them, it becomes as difficult to tolerate sexual as any other form of intense pleasure. Still others, obsessively scrupulous individuals, fear that sex is forbidden because it is immoral and therefore to be avoided without simultaneously putting some form of countervailing cleansing prohibition into place.

In one such cleansing prohibition, the individual can only enjoy intercourse with a lover, but not with a husband or wife, for now, as Freud noted in his 1912 paper, “The Most Prevalent Form of Degradation in Erotic Life,” “the condition of [necessary] prohibition is restored by [the] secret intrigue [of being] untrue.”² Another cleansing prohibition involves having sex, then taking it back, by condemning what one just did immediately afterward, say, with postcoital revulsion manifest as a desire to get away from one’s partner quickly, what one avoidant called my “take a shower and get dressed right now syndrome.” Still another involves keeping tenderness out of sexuality to the point that, as Freud states, a man might actually perceive a “check within him”³ so that, as Jones suggests, he is “only capable of intense physical pleasure with a woman socially, morally or aesthetically of a lower order.”⁴ Frequently, the condition of prohibition is restored by developing strong attractions to many and often only to unavailable people, as does the straight man who pursues serial affairs with prostitutes or the gay man who only likes stevedore types, or by demeaning one’s partners or sexuality itself by picking someone already devalued, say, “rough trade,” or by picking someone valued then demeaning him or her by refuting the value of sexual exclusivity by becoming openly or secretly promiscuous.

A Case Example

Recently, I received the following letter (lightly edited) asking for my advice:

About six months ago, I had a breakup. I was really hurt, and I decided that I was tired of being the monogamous, romantic one who was the only one that seemed to really care and the only one that ever seemed to get hurt. I have since been a slut, in all honesty, going from guy to guy not even caring to learn the person’s name. I honestly have guys in my phone that are labeled “A guy” and “Guy 1,” “Guy 2,” etc. But I am getting tired of not having a someone. Not being loved by a unique partner. Still I feel that all gay guys are stuck up, selfish whores that can’t give a damn about anyone but themselves.

I’m in the military, navy to be exact, and we aren’t exactly allowed to be gay, but everyone knows I am. I met a guy on post about two weeks ago that I slept with and eventually became fond of. I don’t know why really. I have only been with one guy since I met him. I actually care about him. Nowhere near “Love,” but I do care about him. I cry when he’s sad, I smile when he’s happy—a crush if you would. Still I posted an ad the other day on Craigslist looking for sex. I got about 40 responses,

30 of which I accepted and agreed to hook up with within the week. Well, the next day I started thinking. I e-mailed all the guys and told them I was no longer looking for sex. I feel like my life is so fake right now. I would use the commonplace term “empty,” but I don’t like that word. I don’t exactly feel empty, rather full of superficial things that are not really me. Henceforth, I will say I feel “fake”—just compiled of things I don’t really want (but pretend I do).

So, I canceled all these offers. And after about four to five lonely hours of feeling sorry for myself (because I found out that the guy that I like is married and is trying to avoid getting close to

me emotionally), I decided to get up and feel good about myself even with the nothing I have and the nothing I’ve done lately.

I often have low self-esteem. I feel inferior or inadequate. I’m definitely too femme and emotional. I’ve never had a decent relationship that wasn’t online (sadly enough). And I know I have so many great qualities and so many people would be lucky to have me. But why am I attracted to people I cannot have? And why do I attract people that I would not get with? Hopes and dreams are big to me. I am definitely a lover boy and I like to be proper. Exquisite dates. You know, the whole charade. But I often feel like I am being lied to and used by the only guys I meet. I often feel like guys tell me they like me but in the same breath try to push me off. “Oh, sorry, I’m busy. Can we do it tomorrow?” Then I let my emotions take over, and I give them about eight pieces of my mind.

If you have any advice, motivational words, or words of wisdom, such would be highly appreciated. Because I could use all the advice I can get.

Perhaps the commonest cleansing prohibition involves having only virtual sex—displaying an excessive fondness for pornography—which becomes acceptable because it doesn’t involve actual people.

Surprisingly, erotophobic individuals are not necessarily personally cold-blooded types. Outside of the sexual arena, they tend to be normally related people who, though their capacity for sex is diminished, often retain their capacity for personal warmth and affection. Surprising, too, is that unlike individuals suffering from innate sexual avoidance, who claim that “that’s just the way I am,” patients with acquired sexual avoidance tend to be insightful about why they are sexually removed. In contrast to the asexual avoidant who says, “Who knows and even cares why I don’t feel anything,” they often know that they desire sex and have performance difficulties because they have buried their passions, and it is this that leaves them with reduced sexual feelings and ones that they are unable to translate into decisive erotic action.

DEVELOPMENT

More is understood about the development of acquired than of innate sexual avoidance, the latter seeming to “come from out of the blue.” Acquired sexual avoidance in the adult often results when a child’s healthy sexual development is thwarted by unhealthy containment at the hands of rigidly suppressive parents, who encourage the child to carry on his or her parental sexually suppressive tradition, one supported by repressive elements in the society the parents happen to, and often choose to, live in. To illustrate, when he was a child, one avoidant’s mother whipped him whenever she sensed he “felt sexual.” She meted out one particularly intense whipping when she caught him “playing doctor” with a neighbor’s little girl, saying “nice little boys don’t play such naughty games.” After the beating, he “ran away from home” to a neighbor’s apartment, only to be beaten again, this time for disappearing without telling his mother where he was going. After that, his mother tried to make certain that he stayed away from all the girls in the neighborhood so that he didn’t “ruin their lives the way he ruined hers.”

Many parents like this mother are themselves erotophobes, who make it clear that they harbor negative feelings about most or all sexuality. They do this either directly, say, by criticizing the child for masturbation, or indirectly, say, by issuing warnings to “not get married and leave home because your mother needs you.” Children who internalize the parental erotophobia implode sexually and come to view their own sexuality through the eyes of a rigid punitive conscience composed of the adopted harsh, shrill, intrapsychic, hateful, selfdestructive messages antithetical to desire, love, and sex, with no forgiving nuances anywhere to be found to soften the inner blows the conscience rains down on the sexual self.

Sons whose parents humiliated them for normative sexual feelings often go on to develop a fear of masculine sexual activity.

Some Case Examples

A father beat his son and threatened to cut off his funds for school if he did not see a psychiatrist to be cured of being promiscuous, which, according to the father, consisted of his “having more than one girlfriend at a time.” The father’s overall message, “I am ashamed of you for being so sexually preoccupied,” soon became the son’s “I am ashamed of myself and my sexuality.” Next, the son developed a defensive retreat, first into sexual passivity, and then into studied femininity.

As a child, a boy preferred playing with girls. His father, becoming concerned that he would “grow up to be a sissy,” abused him personally by calling him a faggot in order to frighten him straight. Later in

life, the son demeaned himself both for his sexuality and for enjoying almost anything he did, sexual or not. Eventually, the son attempted suicide because “I hate myself so and deserve to die.”

Daughters who grow up with an overly possessive, excessively controlling father may become women with dyspareunia.

A Case Example

A woman’s father repeatedly made the point that he did not want any teenage daughter of his talking to those creeps on the Internet. Then he forbade her to go online at all. Then he declared that she should not date men until she was 30 years old. Then he stopped her from having overnights at houses where there were any men in the household because “who knows what you might do in the way of diddling each other should I leave you alone with them.”

Both parents punished her for “premarital petting” by selling her their house, knowing, but not telling her in advance, that a building project across the way was going to block the ocean view. To rub salt in her wounds, they built a new and better house and gave it to her brother. They also gave him a thriving business they had built up over the years. Almost predictably, their daughter morphed into a selfdestructive, self-hating, remote woman distanced not only from her own family, but also from all potential and actual friends and lovers. She felt too undeserving to enjoy the company of good people and too personally worthless to allow herself to have a great life, especially one that included fulfilling sexual experiences within the context of a happy marriage and big family.

Not surprisingly, early discrete sexual traumata tend to have great lingering inhibitory effects on adult sexuality. In a common scenario, childhood rape or incest experience(s) lead women to view all men as predators, then to detach themselves from adult sexuality because they have come to view all sex, even when consensual, as being forced upon them.

This said, a degree of erotophobia is so common as to be virtually normal. While some is personal due to having introjected negative parental and social messages, some is also innate, part of sexuality’s inherent tendency to elicit guilt in everyone, straight or gay. For reasons not entirely known or explainable, guilt is a universal negative, atti-tudinal mind-set toward having a body and using it sexually, one that makes all sex into something wicked and sinful, unless the sex is between a man and a woman, in the missionary position, in the dark, and strictly for the purpose of procreating—and sometimes even then.

PSYCHODYNAMICS

In contrast to asexuality, which is endogenous, primary, or innate, involving not the presence of conflict, but the absence of discernable desire (and so no determinable conflict), a sexual avoidant’s sexual feelings are there, but suppressed—generally at the behest of a guilty conscience full of shame and embarrassment over having a body and wanting to use it. A belief that sex is sinful develops out of irrational self-criticism for one’s sexual feelings (where rational self-congratulations for being only and fully human are, in fact, indicated). Typically, this guilty conscience is associated with a need for retaliatory masochistic self-torture, which is often additionally externalized to become the sadistic torturing of others, also for their sexuality. Thus a man who hates his own sexuality develops a Madonna complex, where he puts women on a pedestal, while making them feel guilty for being whores, as he makes clear: “You are a woman, and women don’t want sex, or like my mother, may want it but shouldn’t have, and have not actually had it.” (Women put in this nonsensical position often themselves embrace sexual avoidance, hoping that the man will stop debasing and instead start respecting and idolizing them.)

A Case Example

An avoidant man with a Madonna complex felt uncomfortable when he saw his wife’s head turning to look at the display as they passed a pornography shop. He didn’t mind it if he did the looking because he felt that it’s OK to do if you are a man, but he hated to see his wife’s devaluing herself and all women by getting down into what he considered to be the mud and muck of sexuality. He also determined which movies they were allowed to watch at home and in the theater because he worried that his wife would laugh at the double entendres and dirty jokes, revealing that she was just a slut. Ultimately, they couldn’t even attend social events because the men and women there would always talk about sex, and he wanted his wife to neither see nor hear such evil. Central to his guilt-laden relationship with sexuality was the belief that sex was lowly, dirty, and disgusting, a belief that partly originated in his almost daily “appalling rediscovery” that the genitals were too close for comfort to the excretory organs so that touching his wife sexually could lead to his being contaminated by her and getting an infection.

Of course, also contributing to sexual avoidance are the interpersonal, fearful mind-sets characteristic of avoidance in general, especially as shown in table 4.1.

Table 4.1 Fearful Mindsets

Fear of exposure.

Fear of intimacy as confinement.

Fear of yielding, with yielding = dissolution of the self and ego.

Fear of dependency and with it helpless passivity; paradoxically associated with a fear of independence and that with isolative remoteness.

Fear of becoming too emotional and being flooded by overly strong feelings, associated with a fear of letting loose, as if the slightest stirring of emotion might cause all emotions to spin out of control and overwhelm the individual, leaving him or her no longer in charge of the self.

Fear that a demarcating moral line might be crossed.

Fear of failing and being humiliated, often based on a negatively distorted body image that leads avoidants to sell themselves short, expect little, then withdraw defensively to avoid being humiliated and, in a case of misplaced altruism, to keep from disappointing others.

Fear of succeeding then being defeated: in men, castrated, or in women, deemancipated.

Fear of rejection that in turn originates in sensitivity to and readiness to experience even the most positive feedback as shatteringly negative, based in part on excessively high and often perfectionistic expectations of the self and others.

Fear of pleasure on the part of ascetic masochistic individuals who so eschew having fun in any form that they make certain not to take any pleasure and enjoy themselves at all, or at least to do so as little as possible.

Fears that self-assertion = aggressivity, making sex = rape.

Fear of admitting one’s own problems so that others are to be avoided unless they agree to change and be the ones to make all the sacrifices.

SPECIFIC SEXUAL SYMPTOMS

Pathognomonic (characteristic pathological) psychodynamics can sometimes be linked to specific sexual symptoms. Broadly speaking, sexual symptoms tend to be mostly associated with the following:

• an inability to merge intimate and sexual feelings due to an overly scrupulous morality and fear of closeness

• a histrionic fear of genital vulnerability and mutilation

• a generalized regressive mind-set that promotes a throwback to infantilism and with it immature and so infantile sexuality

More specifically, using men as examples, many men with premature ejaculation tend to be excessively impulsive and show a narcissistic lack of concern for a partner’s fulfillment along the lines of “I come when I’m ready to, and who cares about you.” Such men are often also easily bored and want to get it over with so that they can go on to have sex with someone new and presumably more enticing.

Some men with erectile dysfunction may fear that penetrating equates to hurting because the penis equates to a weapon, so they spare the woman in order to avoid brutalizing her. Some are paranoid individuals who see in any mutual attraction the possibility that a woman is forcing them to perform. Still others are sadists, who, devaluing women emotionally and physically, come to feel that no woman deserves anything much from them, so “why give them what they want?”

Men with ejaculatio tarda are often insecure individuals who are spectatoring: observing themselves having sex and making each performance a test of their adequacy, while predictably disparaging themselves for not measuring up—brooding right throughout their performance about what might go wrong (e.g., they won’t be able to come to orgasm) as they constantly judge their sexual prowess as if they are on public display and about to embarrass themselves through failure. Ejaculatio tarda can also arise in the context of an intense fear of closeness due to the belief that closeness equates to merging, or in the context of the histrionic fear that being tender necessarily means being feminine and, as such, becoming emasculated. Further problematic, and perhaps most common of all, is a negative mind-set that won’t allow the man to deny the seamier aspects of sex, leading to frustrated excitement due to the intrusion of negative fantasies originating in disgust.

This page intentionally left blank

CHAPTER 5 Course

Sometimes avoidant personality disorder (AvPD) can improve spontaneously as the individual grows older. This improvement often results when psychological maturity associated with increasing insight based on ongoing introspection and continuous learning are coupled with new fortuitous, corrective social experiences. As a result, the AvPD fades, leaving in its wake self-awareness in the form of the commonplace youth-to-age wisdom expressed as the retrospective amazement of “what was I thinking then, and why did I act as I did?”

At other times, AvPD may not have so favorable an outcome, as the avoidant, succumbing to his or her avoidance, fails to emerge from, or sinks further into, the beckoning quagmire. This often happens because adolescent hormonal fires that stoke relational neediness die down at about the same time that adult relational fears strengthen, societal prohibitions begin to wield greater influence, and new negative interpersonal experiences traumatize the individual, all leading to feelings of resignation and a pervasive sense of doom, accompanied by existential murmurings of hopelessness, creating a generalized inability to experience relational joy. As a result, paraphrasing Berne’s reference to the lonely consequences of playing off-putting games, because avoidants are “not stroked [their] spinal cord[s] . . . shrivel up.”¹ Also, as the years go by, depression can become superimposed on the avoidance, leading to increasing awareness of how much one is missing in life. This depression can also be intensified by escalating isolation due to withdrawal and panicky agoraphobia. Consequences of the depression, such as neglecting one’s appearance and allowing antagonistic behavior toward others to proceed unchecked, may occur along with vicious cycling between withdrawal from, and rejection by, others, ultimately resulting in family members and potential friends and lovers leaving, really being driven away. Millon describes a typical vicious cycle where avoidants’ timidity and shyness antagonize people who withdraw from the avoidant, thinking not, “he is afraid of me,” but “she doesn’t like me”: “the patient’s discontent, outbursts, and moodiness frequently evoke humiliating reactions from others, and these rebuffs only serve to reinforce his self-protective withdrawal. . . . He often precipitates disillusionment through obstructive and negative behaviors [then] reports feeling misunderstood, unappreciated, and demeaned by others.”²

As time goes by, anergia and anhedonia can also appear, as defensive avoidance continues to consume energy that would otherwise be available for relating and diverts it into denying and binding one’s natural /healthy inclinations. Anergia and anhedonia can also appear because second-line defenses develop, bolstering, fixing, and protecting the remoteness. These defenses include hypomanic denial, consisting of resolutely not caring about being loved; inertia in the form of a protective striving for familiarity and sameness; rationalization; identification with the aggressor; and acting out.

RATIONALIZATION

Avoidants who say they want to be alone are often really expressing a fear of connecting. Protesting too much about the splendid nature of isolation, they come to insist (not quite convincingly because of the modest gratification to be obtained from the advantages they list) that “I like being alone because at least my apartment stays straight, I can sleep through without a lover’s snoring, no one stains my upholstery and wall-to-wall rug, and for companionship I have all that anyone needs—my two delightful, loving cats.”

Other rationalizations include the following: ¹

seekers, and easily tiring of what they already have, they pursue the unfamiliar, seeking variety as the only spice in their life.

The world is a terrible place, full of terrible people. Examples follow: “Out there I have nothing but bad luck,” “I never met anyone any good in my whole life,” or in extremely unfavorable cases, “There aren’t any people where I live worthy of me.” A sample uninsight-ful/cruel statement made by a woman in a singles bar as to why she would never try meeting people over the Internet follows: “The creeps in here are bad enough; imagine what I’d find if I actually entered the chat rooms.”

I can’t help myself; it’s not my fault. It is true that some avoidants are in fact so anxious and fearful that they cannot help but retreat when faced with the possibility of forming a relationship. But others, whose anxiety and fear are relative, not absolute, could, if they would, struggle against their anxiety, try to relate, and do so successfully. However, they choose not to use willpower to fight their anxiety. Then, out of shame or guilt about being derelict, they say, not “I choose not to,” but “I can’t.”

The grapes are sour. One patient, afraid of women, thought instead, “Who wants one?” and gave as his reason, “After all, insides beneath that lovely exterior make a woman nothing but a well-packaged bag of dirt,” then added, “and anyway, all wives cheat on their husbands.”

A Case Example

A patient had several ways to rationalize his unrelatedness. He announced, “Relationships are really not that important or essential.” He dwelled on what he believed to be the philosophical meaninglessness of everything interpersonal until, as he later suggested, he became so “preoccupied with the sound of one hand clapping that I can’t erupt into spontaneous applause.” He constantly told himself, “What’s the use of trying to meet someone, we are all going to die anyway?” and convinced himself that the world was a terrible place because of life’s little sardonic twists such as, “You can’t get a partner unless you have relationship experience, and you can’t get relationship experience unless you have a partner.”

Too often, other people buy into such rationalizations, thus perpetuating them. An avoidant friend of mine threw her husband, a PhD psychologist, out of the house after three months of marriage. I mentioned to the psychologist that though his ex-wife later said to me that she couldn’t meet anybody new because there were no eligible men where she lived, I thought that what was keeping her back was not her geographical location, but her personal problems (and he should know all about those!). Yet in spite of his recent firsthand negative experience with her, he shot back that her difficulties weren’t created by, but for, her, due to her being stuck living in the boonies—a place where all the men were already married so that the only men you could meet there were either cheating on their wives or complete losers who stay single not because they want to, but because they have no other choice.

A caveat is that it is necessary to distinguish rationalization from its opposite: guilt about being oneself. In rationalization, things that are feared are turned into matters of natural preference. In guilt about being oneself, matters of natural preference are turned into things that are feared. Thus one woman who wanted to remain single but was embarrassed to say so said, instead, “I am an avoidant, and as such too fearful to even try to connect.”

IDENTIFICATION WITH THE AGGRESSOR

In the realm of identification with the aggressor, relying on how the best defense is a good offense, avoidants reject others as a way to defend themselves against being rejected by them. The idea is to put others down before they can do the same thing to you. Theirs is, however, an unfortunate quest for immediate gratification, without concern for collateral damage and long-term consequences, for they overlook how, in the long run, putting others down changes the avoidant in others’ eyes: from a person to be pitied and succored into one to be feared and ignored.

Finally, avoidance can also worsen with the failure of helpful defenses already in place so that avoidants can no longer handle their anxiety adequately. Now we see panic, increased self-monitoring due to spreading fear, and breakthrough depression accompanied by behavioral regression, appearing because avoidants can no longer deny, and finally have to face, their sad predicament—which, for them, becomes one that they feel entirely helpless to change.

CHAPTER 6

Differential Diagnosis

In this chapter, I discuss differentiating avoidant personality disorder (AvPD) from panic disorder, specific phobia, and social phobia, all Axis I disorders, and from borderline personality disorder, an Axis II disorder.

DIFFERENTIATING AVPD FROM PANIC DISORDER/SPECIFIC PHOBIA/SOCIAL PHOBIA

According to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), patients with panic disorder have discrete anxiety attacks in “places or situations from which escape might be difficult (or embarrassing).”¹ According to Ballenger, these panic attacks commonly lead to avoidance of certain situations “because [the patient] fear[s] that if a panic attack occurred in these settings, it would be embarrassing, frightening, or both.”²

According to the DSM-IV, patients with specific phobia tend to experience “fear[s] that are excessive or unreasonable, cued by the presence or anticipation of a specific object or situation.”³

According to a vast body of literature devoted to “differentiating” AvPD from social phobia, there is no real difference between the two disorders, and AvPD should be subsumed diagnostically under the rubric of social phobia. Thus the Psychodynamic Diagnostic Manual (PDM) calls AvPD “phobic (avoidant) personality disorder”⁴; Anthony and Swinson state that “avoidant personality disorder is just a more intense form of Social Phobia”⁵; and Rettew, wondering if it is possible to diagnose one without the other, notes that APD may represent a more severe form of generalized social phobia with respect to levels of symptoms, fear of negative evaluation, anxiety, avoidance, and depression.⁶

While clearly both disorders overlap psychodynamically, that is, they share many of the same dynamics as feelings of inadequacy and hypersensitivity to negative evaluation, I view the two disorders both as somewhat distinct psychodynamically and as significantly different structurally. For example, many individuals who are, dynamically speaking, shy and withdrawn do not complain of being afraid of speaking in public or of anything like that. Indeed, as many actors point out, as shy people, they actively come alive when on stage, undergoing a kind of temporary antiphobia—what the PDM calls a “converse manifestation: Counterphobic Personality Disorder,”⁷ only to revert to type when the “play” is over.

Millon and Davis also strongly suggest that AvPD and social phobia are two separate entities, for, as they note, social phobia is a symptom (Axis I), while AvPD is a personality problem (Axis 2). Thus, as Millon and Davis say, in AvPD, “there is a pervasiveness and diffuseness to the personality’s socially aversive behaviors, in contrast to the [social phobic’s] specificity of the phobic object and the intensity of the phobic response.”⁸ For characteristically avoidants express their anxiety in the form of what Reich calls “character armoring,”⁹ that is, in pervasive and diffuse interpersonal withdrawal behaviors that run the gamut of severity from modest problems with meeting, mingling with, moving close to, and remaining intimate and involved with other people to full shyness. Conversely, as Millon and Davis suggest, in social phobia, the “phobic symptom is not associated with the broad range of traits that characterize the [avoidant] personality, such as ‘low self-esteem’ [or] the ‘desire for acceptance.’ ”¹⁰ As Benjamin notes, social phobics do not possess the AVD’s sense of being “socially inept [and] personally unappealing, or inferior to others,”¹¹ which lead the patient with AVD and not the social phobic to be “less likely to be married [and more likely to be] content (even relieved) to stay home by himself or herself.”¹²

In short, individuals with AvPD, unlike individuals with social phobia, are not primarily bothered, or bothered at all, by reactive situational anxiety attached to discrete “trivial prompts” such as signing a check in public or urinating in a public restroom—that is, they are not bothered by situations not particularly meaningful in themselves that they make significant by investing them with catastrophic implications. Rather, the life of the typical individual with AvPD is primarily consumed by diffuse, ongoing, dysfunctional relationships characterized by remoteness, shyness, and a tendency to recoil from closeness and intimacy. Patients with AvPD fear closeness, intimacy, and commitment itself, not a symbolic substitute, stand-in, or replacement for those things. In contrast, social phobics withdraw not from interpersonal relationships, but from interpersonal activities that are discrete trivial prompts that symbolize fears associated with interpersonal relationships—neatly packaged, tangible cues that act as stand-ins for interpersonal upheavals condensed and externalized to become outwardly expressed hieroglyphic representations of inner conflict. Because social phobics keep their personality as a whole out of their phobias, they generally remain outgoing and retain the ability to form close and lasting relationships. They might well be happily married and professionally successful. Their problems tend to consist “merely” of troublesome islets of panicky withdrawal—an insular expression of social anxiety that in turn spares the rest of their lives, island(s) of seemingly impersonal difficulty in the mainstream, with a mainland full of satisfactory personal relationships.

Examples of how social phobias refer to specific relational anxieties in a condensed form include a phobia of blushing signifying being criticized for turning red hot sexually; a phobia of speaking in public signifying being exposed as deficient and hence humiliated; a phobia of eating in public signifying being criticized for using the mouth in situations where observed (with homosexual issues implied); a phobia of urinating in a public men’s room signifying exposing one’s genitals to the man standing in the next urinal, in turn implying both homosexual vulnerability and fear of emasculation; and a phobia of signing one’s name to a check while others watch signifying a fear of yielding and hence of being submissive.

Some Case Examples

A patient expressed his generalized social anxiety indirectly and symbolically by pouring it into specific terror about urinating in public and signing his name to a check while others watched. He also condensed his fear of relating into a fear of driving to his partner’s home through green lights and over bridges. He was ultimately able to reach his partner, be romantic, and have sex, only during sex he would suffer from pangs of fear of commitment, which he expressed as a severe ejaculatio tarda (delayed ejaculation) that made it difficult for him to complete the sex act. Dynamically speaking, he was expressing deep interpersonal fears, but structurally speaking, he was expressing them in a condensed and displaced fashion, walling off and containing the fears in short-lived, discrete, pseudointerpersonal encounters that simultaneously referred to, obscured, and to an extent spared the real thing.

This state of affairs contrasts to that which existed with an avoidant, whose interpersonal life was globally tense and unfulfilling. People afraid of public speaking can take a job where they don’t have to do that, but this avoidant could not exist comfortably because he was unable to shake proffered hands, was so fearful of relating that he could not go outside without hiding to some extent, and not only developed an isolating telephonophobia, but also installed an answering machine not to receive, but to screen, messages, then neither answered the phone at all nor returned the messages that people left for him.

I believe that patients with AvPD have effectively made an unconscious choice to deal with their anxieties by developing mild to severe generalized relationship difficulties. In contrast, social phobics have made a different unconscious choice. They have chosen to remain interpersonally outgoing and related. They desire and hope to keep their whole personality out of things, and to do that, they limit their illness to part of their personality only—precisely so that they can remain generally outgoing, although with specific exceptions in the form of delimited deficits.

Importantly, social phobia differs from AvPD in its effect on others. Speaking figuratively, I divide psychological disorders into hot red pepper, garlic, and onion styles. Hot red pepper disorders trouble only the self, “upsetting the stomach,” while others escape distress. Garlic disorders trouble others through “bad breath,” but the self escapes “emotional dyspepsia.” Onion disorders trouble both others and the self as “interpersonal bad breath” accompanies “personal dyspepsia.” While social phobia is a hot red pepper disorder, mainly interfering with one’s own functioning, AvPD is an onion disorder, for it both affects the avoidants’ personal well-being and happiness and is troubling to and detrimental to others in the avoidants’ world.

This said, Benjamin notes that especially troublesome problems of differential diagnosis arise when social phobia generalizes.¹³ This was the case for a socially phobic adolescent afraid of going to school because of a painful startle reaction to the loud school bell. This child soon also became so fearful of all street noise that she was unable to leave the house at all without her mother. Eventually, as an adult, she stayed home with her mother all day, every day, her phobia having spread so that the only meaningful relationships she could have, besides the one with her mother, were the close relationships she developed with her cats.

A careful developmental history can help distinguish patients with generalized social phobia from patients with AvPD. As children, people who go on to develop AvPD are more likely to pull back from others than are people who go on to develop social phobia. The latter as children tend to have normal relationships both at home and outside of the home, for example, they play well with others and their peers aren’t focused on picking on them. But they are more likely to suffer from childhood phobias such as agoraphobia—limiting their movement more than they limit their potential ability to relate.

Therapeutically speaking, social phobics respond to treatment that emphasizes developing cognitive insight into the symptom (“you fear public speaking because you feel that if you make a minor mistake then all will be lost”); informal or formal behavior therapy that offers the patient tasks of graded difficulty geared to overcoming the specific behavioral inhibition(s) involved; and possible pharmacotherapy to reduce anxiety. In contrast, patients with AvPD tend to do best developing insight into the full nature and meaning of the interactive problems that keep them from becoming, and remaining, intimate with significant others. Conversely, it is just common sense that cognitive-behavioral techniques, particularly techniques of graded exposure, will not likely be as helpful for treating an ongoing and generalized fear of closeness, intimacy, and commitment as they might be for treating an encapsulated fear of public speaking. While a patient afraid of public speaking can ask himself or herself, in a reassuring manner, “What is the worst that can happen?” then expose and habituate himself or herself to the anxiety associated with the feared situation until he or she can perform comfortably and safely, shy avoidants afraid of intimacy and commitment have difficulty using exposure methods therapeutically because getting over their “dating anxiety” would require trial intimacies and commitments, which, if at all possible, would be selfish and cruel to others in the extreme.

Invoking an ad hominem argument I base on my own personal observation, I feel that behavioral therapists’ vested interests (in doing behavioral therapy) tend to tempt them to obscure the diagnostic difference between AvPD and social phobia so that they can treat all concerned the same way, that is, behaviorally. In contrast, psychodynamically oriented therapists’ vested interests (in doing insight-oriented, psychodynamically oriented psychotherapy) tempt them to emphasize the differences between a phobic symptom and a personality problem such as AvPD so that they can reserve cognitive-behavioral interventions for the social phobic and use strictly psychodynamically oriented psychotherapy for the patient with AvPD.

¹

don’t have time to meet people. One man placed a personal ad on the Internet and then, making it look as if his work left him no time for fun, arranged to always be too busy to respond to any takers.

I’m not ready; young men like me should play the field a while longer. Some field players are profitably studying the terrain, but many are commitment phobics excusing their inability to play, while others are neophiliacs abandoning old lamps for new because being thrill