“Just the Way I Am”: Denial Is the Enemy of Social Anxiety Sufferers
Confessions of an “Avoidance Addict”
By Amy Lemley
No one would ever call me shy. In fact, I am “the extrovert’s extrovert,” an attention-seeker, a ham. I love public speaking, being interviewed on television and radio, and having my picture taken. I talk to strangers. A lot.
Yet through it all, I have suffered from extreme social anxiety. And I’m not alone. An estimated 37 million people suffer from it in the United States alone. You know some of us, though we are so adept at covering up our fears that you might never suspect.
We are crippled at times by symptoms such as obsessive worry, a racing pulse, clammy hands, and blushing and sweating to such an extent that we’d rather be alone than suffer—no matter what the cost. We may sacrifice relationships. We may sabotage our own careers. We may self-medicate with alcohol and drugs.
However we respond, we do so under a veil of denial wrapped so tightly around us that we cannot move. We don’t know what is wrong. We don’t know there’s a name for it. Our secret is so shameful, our self-hatred so deep, and our belief in our power to change is so diminished that we feel hopeless and unworthy.
“It’s just the way I am…”
Many social anxiety sufferers are labeled “introverts” or consider themselves to be “just shy.” In their view, this is just how they are, an indelible part of their personality. But according to the Andrew Kukes Foundation for Social Anxiety, which reports that one in eight people suffers from social anxiety, a limited awareness of exactly what social anxiety is and how to detect and treat it sentences some people to a life of “less than”—less than happy, less than comfortable, less than successful. (more…)
I believe I have interacted with more individuals with avoidant personalities than anyone in the world! I’m neither bragging nor complaining. It’s just a fact: It’s my job. As a psychotherapist with more than 35 years’ experience specializing in social anxiety—which is commonly comorbid with avoidant personality disorder—I have treated thousands of people with this issue. The overlap between social anxiety and avoidant personality disorder is clear, with avoidant personality disorder involving “more severe and broader areas of personality dysfunction than social [anxiety].” Indeed, the Diagnostic and Statistical Manual of Mental Disorders-5’s identifies social anxiety as a distinguishing characteristic of Avoidant Personality Disorder: “Anxiousness: Intense feelings of nervousness, tenseness, or panic, often in reaction to social situations; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of embarrassment.”2 Avoidance results when these feelings become so intolerable that the person goes to often extreme measures to avoid the situations in which they may occur. As the fear of embarrassment, humiliation and shame increases, the person enters into an avoidance vortex from which they feel like they cannot escape. Narcissistic behavior results, dominating their decision making and behavior. I have often referred to avoidant personality as an addiction and a compulsion because the behavior is so ingrained.
Avoidant personality disorder occurs in an estimated 5.2 percent of the U.S. population annually.3 Social anxiety disorder occurs in 6.8 percent, and within that 6.8 percent, almost 30 percent of cases are considered severe.4 Much academic research exists on the comorbidity of social anxiety and avoidant personality disorder; but very little is available to explore the compulsive nature of avoidance. Therefore, I would like to shed some light on the avoidant personality for the benefit of both clinicians and those who are themselves afflicted with this frustrating and debilitating disorder. After all, individuals with avoidant personality are quite skilled at avoiding, which means that (1) the mental health profession as a whole may have limited access to this group and (2) avoidant people themselves may have found few resources out there to help them recognize their own tendencies and relate to others who share them.5
In my own work, I have identified two subtypes of avoidant personality. The first type of avoidant personality is a certain kind of perfectionist—the kind who feels like nothing he or she does is good enough. In such cases, high functioning is possible unless, for example, the imposed self-pressure to perform becomes too great; at that point, atelephobia—the fear of imperfection, drives avoidance. (Obsessive Compulsive Personality Disorder, which can be characterized as “toxic perfectionism,” may also be present.) The second type of avoidant personality is one in which a person is seized by anxiety about the mental effort involved in overcoming that which they are compelled to avoid. Their response is to detach, and that detachment is so impairing that it leads to dysfunctional dependence and inadequate survival skills; in such cases, the enablers must be taught how not to enable the avoidant person.
The DSM notes that avoidant individuals typically have two characteristics:
- “Low self-esteem associated with self-appraisal socially inept, personally unappealing, or inferior; excessive feelings of shame or inadequacy.”6
- “Unrealistic standards for behavior associated with reluctance to pursue goals, take personal risks, or engage in new activities involving interpersonal contact.”7
And their relationships with others, they are burdened by an impaired capacity for two things:
- “Empathy: Preoccupation with, and sensitivity to, criticism or rejection, associated with distorted inference of others ‟perspectives as negative.”
- “Intimacy: Reluctance to get involved with people unless being certain of being liked; diminished mutuality within intimate relationships because of fear of being shamed or ridiculed.”8
The fear of humiliation in front of and rejection by others—of not being perfect—leads to withdrawal and avoidance: “Reticence in social situations; avoidance of social contacts and activity; lack of initiation of social contact” and “Avoidance of close or romantic relationships, interpersonal attachments, and intimate sexual relationships.”9
To hear the DSM describe it, you might expect avoidant personalities to exist in obscurity, without ever achieving personal or career success. But that is not the case.10 Over the decades, I have treated countless people with avoidant personality disorder who were high achievers, some of them attaining leadership positions and earning substantial salaries. And that is part of what makes this disorder so strange. Despite clear evidence of success—job promotions, high-dollar earnings, social interest both platonic and romantic—some people are unable to shake their fear of criticism and rejection. They are not without talent or charm, and they are very careful to orchestrate circumstances that keep them out of the situations they fear. A brilliant IT innovator, for example, may cope well in an isolated setting and enjoy a steady increase in responsibility and compensation only to succumb to the horror of panic when his next promotion requires public speaking on a regular basis; or perhaps he might avoid all assignments related to public speaking and never receive such promotions at all. A person may be charming enough to be included in a group of friends only to fall out of favor when she fails to take the lead occasionally in making plans or even simply be willing to return phone calls. This same person could function well in a workplace; again, high functioning is possible, even if that success is compartmentalized. Avoidance may be an undercurrent, but it isn’t necessarily a constant.
I recall one patient, “Paul,” who came to me for help at age 48. He had experienced an up-and-down career as a salesman—at one point, he had earned a high six-figure salary, and at other times he had struggled. His social skills were impeccable. Truly, no one in his life would have suspected his fear of rejection and humiliation was running the show to the extent that it was. Selfish? Disorganized? Perhaps. He described his avoidant inclination as “No matter what happens tomorrow; it’s not as important as today.” An example: Rather than take steps to communicate that he needed to cancel a meeting, he avoided the process entirely, creating stress for those who did not know it was cancelled until the last second. He himself felt increasing stress as the meeting time neared and he still hadn’t communicated, and that stress only fed his compulsion to avoid. He was too embarrassed that he had let it go so long, and that paradoxically only led to his letting it go even longer. In treatment with me, he acknowledged that he “had no integrity” when it came to his avoidant strategies. Paul, too, was an expert in detachment.
Researchers have not identified a definitive cause of avoidant personality disorder; it seems likely that it results from both nature and nurture: A set of inborn traits that get either exacerbated by or remain underdeveloped because of circumstances arising in childhood. Personalities are complex, and there is a significant incidence of comorbidity among the different disorders—depression with anxiety disorder, avoidant personality disorder and dependent personality disorder, panic disorder and substance dependence, to name a few examples.11 Are all such disorders fully present and distinct? Or are there simply some overlapping tendencies? In an editorial in the British Journal of Psychiatry, one author argues that considering multiple disorders to be fully present may be overdoing it: “This use of the term ‘comorbidity’ to indicate the concomitance of two or more psychiatric diagnoses appears incorrect because in most cases it is unclear whether the concomitant diagnoses actually reflect the presence of distinct clinical entities or refer to multiple manifestations of a single clinical entity.”12 In my clinical experience, the degree to which one disorder dominates the others is less important than the degree to which beliefs and behavior incapacitate the patient. Full or partial comorbidity is just part of this complex puzzle. Elements of other personality disorders find their way in. For all our reliance on the DSM, not everyone is a textbook case, falling squarely into this or that diagnostic code.
For example, through my extensive clinical experience with thousands of individuals with avoidant personality, I have documented what is not a full comorbidity, necessarily, but a strong overlap that deserves further inquiry: Avoidant personality disorder and narcissistic personality disorder. These may seem at first to be incongruous—where the avoidant thinks so poorly of himself and his abilities that he removes himself from life, the narcissist stereotypically believes the world revolves around him. But the trait is present in avoidant behavior.
Let me provide a few examples so you can see the overlap in action; they elucidate how people with avoidant personality disorder function on a spectrum of emotional and social intelligence.
The previous patient, the high-earning executive named Paul, was also family man and a dedicated father. He coached a number of children’s sports teams. People liked him, and as I explained, no one would have pegged him for an avoidant type who ever experienced social anxiety. Paul got things done and was rewarded for it. Paul was well-liked and outgoing. His suffering was silent and usually—except in those times when his avoidance negatively impacted others—undetected.
Not all avoidant/socially anxious patients are so high-functioning. Other people I’ve treated fall more in line with the “textbook” case the DSM seems to describe. A 26-year-old patient, “Jason,” worked as a paraprofessional in a special education program. His social life consisted of beer drinking and video games with a few friends. Not zero social life, but by no means age-appropriate or well-rounded. And there was no dating. His “independence skills” were quite limited. In fact, he still lived at home in his parents’ basement. It was his parents who eventually initiated treatment; he himself felt no reason to change. He had created his own little world in which he functioned acceptably (to him) and could avoid any of life’s larger challenges. Because he was so good at detaching, he was able to construct an avoidant domain so comfortable that he was unaware any feelings of social anxiety or avoidant pathology existed.
While living at very different functioning levels, Paul and Jason shared a common and insidious dynamic process—and in which you will witness the nature of the narcissism at play as they detach from consequences so as to avoid the extreme discomfort of anxiety.
Paul agreed to a meeting with two other managers and four employees without checking his calendar. Four days before the meeting, as he is closing his calendar app to leave for the day, he notices the conflict. Focused on heading home, he tells himself he’ll address the conflict the next day, quickly putting out of his mind the jolt of discomfort and embarrassment he feels about having double-booked. He goes on to enjoy an evening at home; if the meeting pops into his mind, he quickly squelches the though. Tomorrow, he tells himself. At work the next day, he is involved in other projects—again putting the calendar issue out of his mind even though it would take only minutes to contact the group to let them know. Rather than take a few minutes to address the problem—and more important, to actually feel the feelings of embarrassment, disappointment, foolishness, being a burden, and so on—he suffers hours, and then days of a low undercurrent of anxiety. At times, of course, he is able to ignore the problem entirely. On the day of the meeting, he sends a brief e-mail saying an emergency has come up and he needs to postpone.
Paul let his own need to avoid discomfort dominate the needs of five other people with lives, schedules, and responsibilities of their own—people who may have put off doing things they would have liked to do in order to prepare for his meeting.
Time is our most important resource. It is not elastic. It does not stretch. Violating this resource requires a narcissistic perception that your time is more valuable than other people’s, or that your avoiding uncomfortable feelings is more important than other people’s time. People with avoidant personality disorder behave as though the pain they feel in certain circumstances gives them license to act without consideration for other people. This lack of empathy is common in the avoidant personality. And it is a classic sign of narcissistic personality disorder.
Jason, the special ed assistant, also showed this trait. In the classroom, for example, his students were out of control—getting out of their seats, fighting. He was unsure what to do, but too embarrassed to ask another teacher for help. Instead of trying anything, he did nothing. In fact, he lamely told the class it was reading time and spent the rest of the class period with his own nose in a book, oblivious to the chaos and robbing the students of learning time.
What is the thought process that grants avoidant people the right to behavior that others would call rude, inconsiderate, or irresponsible? What mechanisms are at play? I have engaged in this question with several of my patients in hopes of understanding how this behavior can be so pervasive despite its causing both internal consequences (obsessive worry, self-loathing, guilt) and external ones (jobs, clients, friends, and opportunities for themselves and their families). At what point is the decision made to ignore something and then detach from it in such a way that avoidance is tolerable?
After decades of specialty practice, I would like to augment the DSM description with the following observations. My belief is that for there to be any chance of clinical productivity, the following dynamic must be understood: Social anxiety (the fear of embarrassment, humiliation, or shame) naturally leads to avoidant behavior (the phobia of embarrassment, humiliation, or shame) that results in the compulsion to steer clear of opportunities for those feelings to occur. The more a person acts on this compulsion, the more it becomes ingrained, eventually becoming avoidant personality disorder. As avoidant personality takes hold, rationalization and detachment combine to create a narcissistic vortex into which integrity falls away.
This may seem like a paradox: avoidant personality disorder is characterized by a fear of not being good enough whereas narcissistic personality prompts an image of a grandiose person believing he or she can do no wrong. We think of narcissists as egomaniacs—thinking themselves to be better than everyone else—quite the opposite from the low self-esteem characteristic of the avoidant personality. In fact, narcissism is more about believing oneself to be the center of the world. When an avoidant person chooses to act solely according to his or her own desires, to abandon integrity so as to avoid feelings too comfortable to bear, that person is behaving like a narcissist.
But consider for a moment that fear may underlie narcissism. At the pivotal moment when an avoidant personality elects (however unconsciously) to give in to his or her desire to avoid, the anxiety trigger may be extending beyond the fear of rejection and moving toward what is clinically referred to as “vulnerable narcissism.” Recall our general impression of the narcissist: The stereotypically conceited person who believes his or her every act to be exceptional. Beneath vulnerable narcissism can be something very like social anxiety, however. “For vulnerable narcissistic characters, it is not mere concern about being liked or not [as with social anxiety and avoidant personality disorder]. Rather, the vulnerable narcissist’s fear is that he or she will not be admired…. Their avoidance of relationships is based upon their fear of not being able to tolerate the disappointment of their unrealistic expectations.”13
And therein lies the overlap: The vulnerable narcissist and the avoidant personality may both avoid relationships. When the act of avoidance—the failure to respect other people’s time, in Paul’s case–disappoints or inconveniences others, it becomes something more than just the avoidance of the social interaction for fear of rejection or humiliation. It takes on the vulnerable narcissistic element of shame at failing to measure up to his own self-imposed expectations. Ironically, it is the act of failing and then avoiding itself that causes the person to fail to measure up. Why not cancel the meeting? The social anxiety-plus-avoidance reason is that Paul will feel embarrassed in front of the others whom he is inconveniencing. It feels easier to ignore, avoid, detach. But the vulnerable narcissistic overlay is that he cannot endure the feelings of self-judgment for overbooking, for failing to be perfect in his own eyes.
The compulsion to escape what to the avoidant personality is humiliation but to others is just part of life is looming. Their feelings are the only ones that matter. In all our lives, schedule conflicts come up. People forget things. People don’t finish things when they expect to. But avoidant personalities have made those facts embarrassing. Mortifying. Tortuous. They can’t say “I need to reschedule,” “I’m running late,” “I didn’t win the contract.” Their avoidance tells them to flee the shame of humiliation in front of others. Their vulnerable narcissism tells them to flee the knowledge that they are not the perfect being they expect themselves to be. The only way to cope is to dissociate. And so the sepsis of avoidance takes hold.
What follows is a rare interview with “Kim,” who has lived with avoidant personality since childhood. Kim is dynamic, outgoing, and successful—and yet she suffers from social anxiety that leads to avoidant behavior, placing personal and professional relationships at risk. It was after a conversation in which I suggested that narcissism rather than avoidance was leading her to miss deadlines and avoid phone calls that she eagerly agreed to discuss her experience. “I never thought of it that way!” she said. The authentic nature of her narrative should add dimension to the understanding of this elusive pathology.
One Day at a Time: Recovering from an Avoidance Bender
There’s a magic trick I do. I disappear. I can be right there with you—all in—making big social plans, embarking on fascinating work projects, dazzling, devoted. And then I’m gone.
Your phone calls go unanswered. My promised email never comes.
The screen has gone dark and I’m nowhere.
But of course I am somewhere—with the phone in my pocket, perhaps at the computer, but unconscious to my obligations, behaving like I’ve forgotten everything I’d agreed to do.
I’m not drinking. I’m not doing drugs. I’m on an avoidance bender, compelled to ignore my obligations and detached from the things I’ve agreed to do and the people who are counting on me to complete a project or return a phone call.
How the hours and days seem to pass so quickly, I am not sure: Sometimes, I may be especially active, as though distracting myself from the tasks I am avoiding: I’ll poke around in thrift stores, help a friend reorganize her closet, or work on another, less urgent thing that’s somehow easier to take on in that moment. But other times, I’m in a fog, clear-headed enough to know I should be taking care of things, but still willing to allow time to pass, unstructured, unproductively, and uncommunicatively. Those times, I’m not doing much at all, just puttering.
How do I go from responsible professional and loyal friend to master of avoidance? I detach. It’s not a conscious decision. It’s a compulsion that I am sometimes aware of, and sometimes oblivious to. At first, I experience a burdensome dread—a lump in my throat or heart palpitations as I worry about my obligations. “I should really call so-and-so back” or “I know I won’t be finished on time. I should send an e-mail to say so.” But I’ll put the task on the back burner. As the hours and days go by, I might consider doing the right thing, but then I put it off. At some point, I detach from it—relegating from the back burner to a cabinet with a door I can close. On a conscious, day-to-day level, I know it’s there—this task I should complete. I may even consciously realize the task won’t take that long. I spend more time worrying than the task itself would take. Once I get to a certain level of detachment, the uncomfortable feelings are replaced by a “me first” feeling, and the worry is all but imperceptible.
This is how it typically goes: I take a project, one I can do well in the time allotted, usually, or one for which I envision myself doing the impossible, completing it in half the time I know deep down it should take. But as the deadline approaches, my inspiration or sense of duty fails to ignite. A Friday deadline becomes a Monday one—what’s the difference? I ask myself. It’s not like my colleague will work on this over the weekend. (Nor will I, as it turns out, despite my visions of “all the time in the world” to spend Saturday or Sunday.) I decide to ride a wave of urgency Monday morning. As Duke Ellington said, “Inspiration, hell! Give me a deadline!” But Monday rolls around, and what I fantasized was a quick project begins to take more time than I’ve allowed. I set it aside and I’m on to the next thing—usually whatever’s new or whatever requires face time with someone else. Surely I can wrap up the first project Monday evening.
But I don’t.
And I don’t say that I won’t. If no one calls, I pretend no one has noticed that I am AWOL. In my case, rather than Absent Without Leave, I’d call it AWOI: Absent Without Integrity. Integrity is what’s missing, but I choose not to restore it—by being accountable for my lapse and providing an accurate estimate of when I will honor my commitment…and then doing it.
When I do surface, I am mortified. I feel sick. Sometimes, the people I work for don’t seem to care—though the rational part of me realizes they must see me as irresponsible. In fact, I am sure I’ve made a lot of people furious. I’ve wasted their time—time they cannot get back. I may have compromised their own relationships or projects, putting their reputations at risk.
Sometimes, though less often than you’d think, they address the issue. One colleague said, “As soon as you turned in your first draft”—which was late— “I felt like you disappeared. You didn’t check in once to see if I had all I needed.” Another told me, “I don’t want to have to manage you”—which he shouldn’t have to do, but I was making so little progress between our meetings that I seemed to barely be moving.
It’s amazing I could take this criticism without tears, but I always have. I take my lumps. I feel like I’ve failed, which I have. But I’m not surprised.
I’ve come to expect it of myself. I recall how years ago, I caught myself inventing an excuse for why I was late on an assignment as soon as I received it. That right there tells you there’s more to it than just running out of time. It’s like I am orchestrating my own humiliation—planning to fail even while there is still plenty of time to plan to succeed.
I complain (to myself) about my irresponsibility/lack of integrity/time mismanagement, but I continue to goof off when I should be working, to lounge around, watch TV, sit in the garden, zone out. I’m a consultant and work from home so there is plenty of opportunity for those things; when I worked in an office, I zoned out in other ways but to this day I cannot remember what I was doing. Am I lazy? Irresponsible? Bad at managing time? A jerk? Worse than a jerk?
I choose “all of the above.” People may or may not be saying these things about me but it doesn’t matter. I badmouth myself to myself. And I do apologize to others. A lot. I recommit. I get back on the horse. But I continue with the same masochistic behavior. Yes, masochistic—I am doing something to myself that causes me pain, pain that I desire in some way, or else I wouldn’t keep behaving like this. The pain I cause—the humiliation, shame, and guilt—are not pleasant in and of themselves, but the pain has a sickening benefit, one I’m not consciously aware of.
As I float along in my avoidance Neverland, this murky masochistic undercurrent lurks. I can identify at least two “benefits” I gain through this masochism. For one thing, I get to be right about myself and make others wrong: Inwardly, part of me believes I’m not good enough, despite decades of evidence to the contrary (I have friends who love and trust me, I make a living in my chosen field, etc.). Shirking my obligations gives me proof that I’m not good enough again and again. I “make others wrong” by demonstrating that their confidence in me was misplaced. The second thing is that I get to dominate others and avoid being dominated: Feels a little bit like a little kid with crossed arms yelling, “You’re not the boss of me!”
I’m excellent in my field. I’m not always (which equates to never) reliable. My net value? Zero. It’s not just missing work deadlines. My social life suffers too.
have good intentions. I do. In the moment. I’m a visionary. I’m a cheerleader. I say “yes and.” Someone once called me the extravert’s extravert—and I guess that’s right. What that person couldn’t know is that an undercurrent of social anxiety is rotting that outgoing foundation.
It’s a common business adage to say “underpromise and overdeliver.” I do the opposite. In my little Neverland, everything is possible. That may mean staying up all night to finish a project. That may mean having lunch twice in one day because I couldn’t say no or felt awkward about changing plans.
Am I just too busy? No. In fact, it’s having too much flexibility that gets me in the most trouble. Long stretches of time draw me into Neverland. Days and weeks can go by while a long-term, or long-passed, deadline looms. And as I said, it’s like I enter a fog—sometimes filled with busy-ness, but sometimes slow motion, with nothing much going on at all. I tell myself, “I won’t listen to the voicemail. I’ll just call her back later.” And that becomes “I’m embarrassed I haven’t called her back.” And that becomes “My God, what if somebody died and I haven’t called her back.” This can go on for weeks. When at last I listen to the voicemail, heart pounding, I am relieved beyond measure that it was just a hello call.
I’ve lost touch with longtime friends for several years at a time because I was too embarrassed that I had failed to return their phone calls. That’s right: embarrassed. Mortified. You see, it’s not that I feel good about my whirlwind detours. Far from it.
It’s a lot like going on a drinking bender: You’re the life of the party, everybody loves you, and the world is a beautiful, sparkly place. But then you wake up the next morning, horrified by what you can remember about how you behaved.
When I come back from Neverland for a moment—because of a colleague’s e-mail(s), a friend’s text message(s)—I am mortified. What could I possibly say that would make this all right?
Accountability only goes so far. Pretending it never happened stays uncomfortable—at least for me, and probably for all concerned.
Prevention is the only cure. A few sentences get me back on track: “Do it now” is one of those. “What’s the best use of your time at this moment?” is another. I’ve also found help in the Integrity Cheat Sheet in Work Makes Me Nervous: Overcome Anxiety and Build the Confidence to Succeed:
- Do what you said you would do and do it on time.
- Do what others would expect you to do even if you didn’t say you would do it.
- Do it the way it was meant to be done.
- Acknowledge that you won’t be doing it, or won’t be doing it on time, as soon as you realize that, and deal with the consequences.
When you’re an avoidant by nature, susceptible to benders, that simple cheat sheet can become your Serenity Prayer.
- Eikenaes, I., et al. (2013) “Personality Functioning in Patients with Avoidant Personality Disorder and Social Phobia.” Journal of Personality Disorders. 27:6, 746-763.
- Diagnostic and Statistical Manual of Mental Disorders-5. Arlington, VA: American Psychiatric Association, 2011.
- Lenzenweger, M. F., Lane, M. C., Loranger, A.W., Kessler, R. C. (2007). “DSM-IV personality disorders in the National Comorbidity Survey Replication.” Biological Psychiatry, 62(6), 553-564.
- Kessler, R. C., Chiu, W. T., Demler, O., Walters, E. E. (2005). Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R).” Archives of General Psychiatry. Jun;62(6):617-27.
- To date, the most accessible resource Dr. Martin Kantor’s Distancing: Avoidant Personality Disorder (Elsevier Books), an academic title targeted to clinicians that retails for $60; this book presents case studies from the clinical perspective, with most of the text devoted to treatment strategies.
Diagnostic and Statistical Manual of Mental Disorders-5.
- Diagnostic and Statistical Manual of Mental Disorders-5.
- Diagnostic and Statistical Manual of Mental Disorders-5.
- Diagnostic and Statistical Manual of Mental Disorders-5.
- Diagnostic and Statistical Manual of Mental Disorders-5.
- Eikenaes et al.
- Maj, M. “‘Psychiatric comorbidity’: an artefact of current diagnostic systems?” (2005). The British Journal of Psychiatry. 186 (3), 182-184.
- Kelly, A., and Pincus, A. (2003). Journal of Personality Disorders, 17(3), 188-207.