PANCE Blueprint Psychiatry (6%)

Personality Disorders (Lecture)

Personality Disorders (Flashcards)

Personality Disorders (Key Points)

Histrionic Histrionic Personality Disorder


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Key Points

  • Attention seeker, overly emotional
DSM-5 Diagnostic Criteria

DSM-5 Diagnostic Criteria

A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

  1. Is uncomfortable in situations in which he or she is not the center of attention.
  2. Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.
  3. Displays rapidly shifting and shallow expression of emotions.
  4. Consistently uses physical appearance to draw attention to self.
  5. Has a style of speech that is excessively impressionistic and lacking in detail.
  6. Shows self-dramatization, theatricality, and exaggerated expression of emotion.
  7. Is suggestible (i.e., easily influenced by others or circumstances).
  8. Considers relationships to be more intimate than they actually are.

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IM_NUR_HistrionicPersonalityDisorder_v1.2_ Histrionic personality disorder is characterized by colorful and emotionally dramatic extroverted behavior. Individuals with this order feel the need to be the center of attention and demonstrate flirtatious behavior while dressing for attention. Their labile emotions and dramatic behavior cause them to have difficulty maintaining long-lasting and intimate relationships. They are quick to follow fads and have impressionistic speech.

Histrionic Personality Disorder Picmonic

Schizoid and Schizotypal Schizotypal Personality Disorder


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Key Points

  • Discomfort with social and interpersonal relationships. Odd, eccentric behavior.
DSM-5 Diagnostic Criteria

DSM-5 Diagnostic Criteria

  1. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:
    1. Ideas of reference (excluding delusions of reference).
    2. Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”; in children and adolescents, bizarre fantasies or preoccupations).
    3. Unusual perceptual experiences, including bodily illusions.
    4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, over elaborate, or stereotyped).
    5. Suspiciousness or paranoid ideation.
    6. Inappropriate or constricted affect.
    7. Behavior or appearance that is odd, eccentric, or peculiar.
    8. Lack of close friends or confidants other than first-degree relatives.
    9. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.
  2. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder.
    • Note: If criteria are met prior to the onset of schizophrenia, add “premorbid,” e.g., “schizotypal personality disorder (premorbid).”

Schizoid Personality Disorder

Key Points

  • Inability to form and maintain meaningful personal relationships. Neither desires nor enjoys close relationships, including being part of a family.
DSM-5 Diagnostic Criteria

DSM-5 Diagnostic Criteria

A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

  1. Neither desires nor enjoys close relationships, including being part of a family.
  2. Almost always chooses solitary activities.
  3. Has little, if any, interest in having sexual experiences with another person.
  4. Takes pleasure in few, if any, activities.
  5. Lacks close friends or confidants other than first-degree relatives.
  6. Appears indifferent to the praise or criticism of others.
  7. Shows emotional coldness, detachment, or flattened affectivity.

B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, another psychotic disorder, or autism spectrum disorder and is not

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IM_NUR_Schizoid-Personality-Disorder_V1.3_ Schizoid personality disorder is characterized by an inability to form and maintain meaningful personal relationships. They lack close relationships with others and enjoy solitary activities. They find little interest in having sex. Individuals with schizoid personality disorder present with a flat affect and are indifferent to praise.

Schizoid Personality Disorder Picmonic

Congratulations - you have completed Schizoid personality disorder. You scored %%SCORE%% out of %%TOTAL%%. Your performance has been rated as %%RATING%%
Your answers are highlighted below.
Question 1
A 46-year-old-man presents to a primary care physician with a chronic cough. He reports that he has not seen a physician in 25 years, but he has not been sick during this time. He lives in a cabin in the woods, and although he does not have any friends, he reports that he does not feel lonely. He is well-groomed, dressed normally, and does not have any bizarre beliefs. He describes his mood as "fine", and his speech is fluid, albeit limited in amount. His thought process is linear, and his thought content is appropriate. He denies any visual or auditory hallucinations. Which of the following is true about this patient's psychiatric condition?
A
It has a high correlation with schizophrenia
Hint:
Schizotypal, not schizoid, personality disorder is related to schizophrenia.
B
The patient should be treated with an antidepressant
Hint:
Since this patient does not present with symptoms of co-morbid depression, he does need to be treated with antidepressants.
C
No specific treatment is needed at this time
D
The patient is likely very responsive to criticism and praise
Hint:
Patients with SPD are often indifferent to praise or criticism, and likewise do not offer praise or criticism as readily as non-affected patients.
E
The patient likely suffers from a co-morbid substance use disorder
Hint:
Patients with antisocial, borderline, or schizotypal personality disorders are likely to have substance use disorders, but not patients with schizoid personality disorder.
Question 1 Explanation: 
This patient's clinical presentation is consistent with schizoid personality disorder (SPD), which does not require treatment, unless the patient presents with a co-morbid Axis I disorder, such as depression, psychosis, or anxiety.
Question 2
What behavior would be most typical for a patient diagnosed with schizoid personality disorder?
A
Chooses solitary activities
B
Odd thinking and speech
Hint:
Schizotypal personalities have this along with magical thinking and ideas of reference. They may become withdrawn due to the lack of acceptance.
C
Reckless disregard for safety of others
Hint:
Reckless disregard for safety of others is typical of antisocial personality disorders.
D
Uses physical appearance to draw attention
Hint:
Using physical appearance to draw attention is more typical of histrionic disorder.
Question 2 Explanation: 
Persons with schizoid personalities are very withdrawn and do not seek or enjoy relationships and are indifferent to praise or criticism. They generally appear cold and unfeeling to others.
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Borderline Borderline Personality Disorder


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Key Points

  • Poor impulse control, poor self image, unstable interpersonal relationships
DSM-5 Diagnostic Criteria

DSM-5 Diagnostic Criteria

A pervasive pattern of instability of interpersonal relationships, self image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

  1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
  2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
  3. Identity disturbance: markedly and persistently unstable self image or sense of self.
  4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
  5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
  6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
  7. Chronic feelings of emptiness.
  8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
  9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

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IM_NUR_Borderline-Personality-Disorder_V1.2_ Borderline personality disorder is characterized by chaotic relationships, labile mood, and fluctuating attitudes toward other people. They have poor self-image and chronic feelings of emptiness. Fear of abandonment prevents them from maintaining stable relationships. Common personality traits include splitting and anxiety. Self-destructive behavior and suicidal thoughts are classic manifestations of this disorder.

Borderline Personality Disorder Picmonic

Narcissistic Narcissistic Personality Disorder


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Key Points

  • Need for admiration, grandiose thoughts, concerned about what others think yet lack empathy
DSM-5 Diagnostic Criteria

DSM-5 Diagnostic Criteria

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

  1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
  2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
  3. Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high status people (or institutions).
  4. Requires excessive admiration.
  5. Has a sense of entitlement (i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations).
  6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends).
  7. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
  8. Is often envious of others or believes that others are envious of him or her.
  9. Shows arrogant, haughty behaviors or attitudes.

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IM_NUR_Narcissistic_V1.3_ Narcissistic personality disorder can be described as a condition in which people have an excessive sense of self-importance, lack empathy for others, and possess an extreme preoccupation with themselves causing them to seek the admiration of others. Beginning by early adulthood and present in a variety of settings, people with this personality disorder may inflate their accomplishments, get easily angered when criticized, show little interest in others experiences, and require excessive admiration.

Narcissistic Personality Disorder Picmonic

Question 1
Which of the following is a recognized criterion for NPD, according to the DSM-5?
A
Interpersonally exploitive behavior
B
A high degree of empathy that is willingly rejected
C
An absence of empathy toward others
D
None of the above
Question 1 Explanation: 
In DSM-5, NPD is defined as comprising a pervasive pattern of grandiosity (in fantasy or behavior), a constant need for admiration, and a lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by the presence of at least five of the following nine criteria over a significant time period:
  • A grandiose sense of self-importance (eg, the individual exaggerates achievements and talents and expects to be recognized as superior without commensurate achievements)
  • A preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love
  • A belief that he or she is special and unique and can only be understood by, or should associate with, other special or high-status people or institutions
  • A need for excessive admiration
  • A sense of entitlement (ie, unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations)
  • Interpersonally exploitive behavior (ie, the individual takes advantage of others to achieve his or her own ends)
  • A lack of empathy (unwillingness to recognize or identify with the feelings and needs of others)
  • Envy of others or a belief that others are envious of him or her
  • A demonstration of arrogant and haughty behaviors or attitudes
For more on the background of NPD, read here.
Question 2
Which of the following statements is accurate regarding NPD?
A
NPD typically does not manifest until mid-adulthood (age > 30 years)
B
The incidence of NPD is equal between men and women
C
NPD is frequently associated with comorbid axis I diagnoses
D
In general, NPD lessens over time as the individual ages
Question 2 Explanation: 
Patients diagnosed with NPD are more likely to have comorbid axis I diagnoses, such as major depressive disorder, bipolar disorder, substance-related disorders (specifically related to cocaine and alcohol), anxiety disorders, and anorexia nervosa. Such patients may develop suicidal ideation. NPD manifests by young adulthood (early to mid-20s) and may worsen in middle or old age as a consequence of the onset of physical infirmities or declining physical attractiveness. NPD is more commonly found in males than in females; of those diagnosed with the disorder, approximately 75% are male. No racial or ethnic predilection has been identified. For more on NPD, read here.
Question 3
Which of the following statements is accurate about the presentation of NPD?
A
Eye contact is typically avoided
B
The patient is frequently disoriented to person, place, and time
C
NPD is typically diagnosed alone, without known comorbid conditions
D
A depressed mood due to dysthymia or major depressive disorder may be noted
Question 3 Explanation: 
NPD is not associated with any specific defining physical characteristics. Mental status examination may reveal depressed mood due to dysthymia or major depressive disorder, both of which may be related to the paradoxically low self-esteem often present in patients with NPD. Because NPD, by its nature, involves a haughty disregard for others and an insistence on one's own innate superiority, narcissistic patients are unlikely to recognize their need for treatment and even less likely to seek help of their own accord. For this reason, patients with a diagnosis of NPD alone (ie, with no concomitant axis I diagnoses) make up a very small percentage of the total patient population seen by mental health professionals. For more on the presentation of NPD, read here.
Question 4
Which of the following statements is accurate about the workup of NPD?
A
A toxicology screen is generally recommended
B
Specific personality tests are required for definitive diagnosis
C
Diagnosis requires obtaining a history from the patient's family and friends
D
Cognitive function testing is strongly encouraged
Question 4 Explanation: 
No specific laboratory studies are used to diagnose NPD. Nevertheless, in view of the high incidence of substance abuse in patients with this disorder, a toxicology screen to rule out drugs and alcohol as possible causes of narcissistic character pathology is generally recommended. The diagnosis of NPD is often made after obtaining a history of narcissistic symptoms from pertinent sources (including the patient, the patient's family and friends, and the clinician's own observations). However, more specific personality tests can also be used to facilitate diagnosis. Some debate surrounds the usefulness and reliability of these tests, but they can be helpful in elucidating character pathology outside the strict confines of the criteria listed in the DSM-5. For more on the workup of NPD, read here.
Question 5
Which of the following statements is accurate regarding the treatment of NPD?
A
Psychotropic medications are used to specifically treat NPD
B
The mainstay of treatment is individual psychotherapy
C
Patients with NPD may benefit from prolonged inpatient treatment
D
Group therapy should be initiated in almost all patients with NPD
Question 5 Explanation: 
Over the long term, consistent outpatient care is the approach of choice in the treatment of NPD. This usually involves a combination of psychotherapy and medication management. The mainstay of treatment is individual psychotherapy—specifically, psychoanalytic psychotherapy. Psychotropic medications are not specifically used to treat NPD but are often used to treat concomitant anxiety, depression, impulsivity, or other mood disturbances or if the patient becomes significantly depressed, anxious, or suicidal during psychotherapy. Besides individual psychoanalytic psychotherapy, group therapy and cognitive-behavioral therapy have also been used to treat NPD. Group therapy was initially thought to be unsuitable for patients with narcissism because clinicians assumed that these patients would be unable to handle the requisite give-and-take inherent in the group process. This initial assumption about the unsuitability of group therapy was reasonable, in that group processes usually require empathy, patience, and the ability to relate and connect to others—traits that are deficient in narcissistic individuals. Nevertheless, studies have suggested that long-term group therapy can benefit patients with narcissism by providing them with a safe haven in which they can explore boundaries, receive and accept feedback, develop trust, and increase self-awareness. If the patient acutely decompensates or becomes a danger to self or others, inpatient treatment is warranted. As a rule, shorter hospital stays are best for patients with NPD; prolonged time in the hospital will do little to change the underlying severity of the illness. Hospitalization should only be used as a temporizing measure to allow stabilization of environmental stressors, adjustment of medication dosages, or both. For more on the treatment of NPD, read here.
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Anti-social Antisocial Personality Disorder


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Key Points

  • No concern for others, neglect of dependents, lack of remorse, morals or empathy
  • Must occur before age 15
DSM-5 Diagnostic Criteria

DSM-5 Diagnostic Criteria

  1. A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by three (or more) of the following:
    1. Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.
    2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.
    3. Impulsivity or failure to plan ahead.
    4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
    5. Reckless disregard for safety of self or others.
    6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.
    7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.
  2. The individual is at least age 18 years.
  3. There is evidence of conduct disorder with onset before age 15 years.
  4. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder.

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IM_NUR_Anti-Social_v1.5_ Antisocial personality disorder is characterized by socially irresponsible behavior, with disregard for others. Personality characteristics include ego-centrism, disregard for others, self-esteem from personal gain, and lack of empathy and intimacy. They demonstrate antagonistic, manipulative, hostile, and inhibitive behaviors. Diagnosis requires a history of conduct disorder and being over the age of 18.

Antisocial Personality Disorder Picmonic

Obsessive-Compulsive Personality Disorder Obsessive-Compulsive Personality Disorder


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Key Points

  • Preoccupation with perfectionism attempts to control interpersonal relationships, obsessive thought and performance of compulsions impede daily functioning.
DSM-5 Diagnostic Criteria

DSM-5 Diagnostic Criteria

A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

  1. Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost.
  2. Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met).
  3. Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity).
  4. Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification).
  5. Is unable to discard worn-out or worthless objects even when they have no sentimental value.
  6. Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things.
  7. Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes.
  8. Shows rigidity and stubbornness.

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IM_NUR_ObsessiveCompulsivePersonalityDisorder_v1.2_ Obsessive-compulsive personality disorder is characterized as being extremely inflexible with rules and behaviors. Individuals are overly disciplined with their workload and unable to adjust their standards. They have great difficulty understanding the perspectives of others and have a strong desire to control situations. By carrying out established standards, they are perfectionists and extremely perseverant in their assignments.

Obsessive Compulsive Personality Disorder Picmonic

Paranoid Personality Disorder Paranoid Personality Disorder


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Key Points

  • Paranoid personality disorder is characterized by persistent feelings of suspiciousness and mistrust of other people.
DSM-5 Diagnostic Criteria

DSM-5 Diagnostic Criteria

A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

  1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her.
  2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.
  3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her.
  4. Reads hidden demeaning or threatening meanings into benign remarks or events.
  5. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights).
  6. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack.
  7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.

B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive disorder with psychotic features, or another psychotic disorder and is not attributable to the physiological effects of another medical condition.

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IM_NUR_Paranoid_personality_Disorder_V1.3_ Paranoid personality disorder is characterized by persistent feelings of suspiciousness and mistrust of other people. Patients with paranoid personality disorder are preoccupied with analyzing social interactions and are constantly suspicious of trusting others without underlying reasons. They are reluctant to confide in others and tend to hold grudges. They misinterpret others' remarks and perceive them as personal insults.

Paranoid Personality Disorder Picmonic

Dependent Personality Disorder Key Points

  • Dependent personality disorder is characterized by behaviors demonstrating an excessive need to be taken care of
DSM-5 Diagnostic Criteria

DSM-5 Diagnostic Criteria

A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

  1. Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others
  2. Needs others to assume responsibility for most major areas of his or her life.
  3. Has difficulty expressing disagreement with others because of fear of loss of support or approval. (Note: Do not include realistic fears of retribution.)
  4. Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy).
  5. Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant.
  6. Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself.
  7. Urgently seeks another relationship as a source of care and support when a close relationship ends. 8. Is unrealistically preoccupied with fears of being left to take care of himself or herself.

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IM_NUR_DependentPersonalityDisorder_v1.2_ Dependent personality disorder is characterized by behaviors demonstrating an excessive need to be taken care of. People with this disorder fear separation and are submissive to others. They have difficulty making their own decisions and have an exaggerated fear of being unable to take care of themselves. Since they are uncomfortable being alone, they urgently seek new relationships after breakups. They have difficulty initiating new projects and disagreeing with others. To obtain a sense of comfort, they will go through excessive lengths to be nurtured by others.

Dependent Personality Disorder Picmonic

Avoidant Personality Disorder Avoidant Personality Disorder


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Key Points

  • 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.
DSM-5 Diagnostic Criteria

DSM-5 Diagnostic Criteria

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, as indicated by four (or more) of the following:

  1. Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection.
  2. Is unwilling to get involved with people unless certain of being liked.
  3. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.
  4. Is preoccupied with being criticized or rejected in social situations.
  5. Is inhibited in new interpersonal situations because of feelings of inadequacy.
  6. Views self as socially inept, personally unappealing, or inferior to others.
  7. Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.

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avoidant-personality-disorder_6134_1496962305 Avoidant personality disorder is characterized as being hypersensitive to rejection. Extreme feelings of shyness and fear cause these individuals to be very socially withdrawn despite wanting relationships with others. They have feelings of inadequacy and low self-esteem. Persons with avoidant personality disorder experience anhedonia and anxiety that prevent them from establishing healthy relationships with others.

Avoidant Personality Disorder Picmonic

Autism spectrum disorder (Prev Lesson)
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