October 16, 2012
By Cortney Casey, C & G Staff Writer
The approximately 250 strangers conversing amongst themselves fell silent and turned their attention to Patty Kukes as she stepped to the podium on Sept. 27.
It was the kind of setting that would have constituted her son Andy’s worst nightmare. But that was precisely the point of “Misunderstood No More,” a presentation put on by the Andrew Kukes Foundation for Social Anxiety and hosted by Macomb County Community Mental Health Services.
“I’m very nervous today. I’m not a public speaker, but I’m up here in front of all of you,” said Patty Kukes, flanked by her ex-husband, Jeff. “Our son, Andy, couldn’t have even walked into this room. He had social anxiety — and it literally killed him.”
Andy, she said, “had every chance at a wonderful life.” He was an athlete, valedictorian of his high school class and a Princeton graduate. But even after seeking help from a series of therapists, he became virtually homebound “because he was so afraid of being judged, how his performance would be perceived,” she said.
Andy Kukes fatally shot himself July 14, 2009. He was 30 years old.
His suicide prompted the family — originally from Bloomfield Hills, now living in Florida — to launch a nonprofit organization in his memory in hopes of preventing future tragedies.
Social anxiety is particularly daunting to treat because it doesn’t manifest itself as obviously or outwardly as a severe physical injury or disease, yet its consequences can be equally grave, said Patty Kukes.
“If someone is blushing when they’re talking to you and sweating and very distressed and can’t look you in the eye, they’re sick on the inside,” she said. “Is it best to ignore that? Can we help them? Is it best to walk away?”
Social worker Jonathan Berent, who’s worked with social-anxiety patients since the mid-1970s, addressed those questions and more during the presentation, before a crowd of health-care professionals and laypeople at the Best Western Plus Sterling Inn Banquet & Conference Center Sept. 27.
As social anxiety is a disease of detachment, the key is getting patients to attach — which means they need to get comfortable with being uncomfortable, said Berent, author of “Beyond Shyness: How to Conquer Social Anxieties” and “Work Makes Me Nervous: Overcome Anxiety and Build the Confidence to Succeed.”
Social anxiety sufferers often develop a sense of hyper-vigilance in childhood, “a defensive radar that can cause burnout” as the nervous system works overtime, said Berent.
They start believing a never-ending internal script that tells them they’re inferior. Anxiety typically leads to avoidance, and sufferers often put off seeking treatment or turn to the Internet for “magic” remedies, he said.
Addressing adrenaline control is among treatment techniques, said Berent. Patients are encouraged to have realistic expectations: Instead of hoping an uncomfortable situation won’t spark an adrenaline rush, “accept the adrenaline-driven visceral response as a source of power and your friend,” he said.
Take one or two diaphragmatic breaths, then “surf” the wave of adrenaline instead of resisting it, he said.
“The surfer goes with the adrenaline; he or she is in control,” he said. “You do not go with it, you get smashed around. That’s a panic attack.”
According to Berent, working with enablers in the patient’s life also is crucial. If parents are contacting a therapist on their child’s behalf, they need to come in to get on board with the system of treatment, he said.
Besides events like the Sept. 27 community presentation, the Andrew Kukes Foundation offers two versions of a 10-hour intensive course helmed by Berent: one on DVD for professionals pursuing educational credits and one online for families, who can watch it for a donation, said Lori Blumenstein-Bott, the organization’s executive director.
Through its website, the foundation also is offering webinars with subject-matter experts, live-stream discussions with Patty and Jeff Kukes, questionnaires assessing social anxiety symptoms, aggregated relevant articles, links and other resources.
“Through awareness and education, the conversation begins,” said Blumenstein-Bott. “That’s how we want to build that message on a national level. The more lives you touch with this, the more people start talking about it.”
For more information on the Andrew Kukes Foundation for Social Anxiety, visit www.akfsa.org or call (561) 921-5151.
You can reach C & G Staff Writer Cortney Casey at email@example.com or at (586)498-1046.
The story of Rip Van Winkle is set in the years before and after the American Revolutionary War. In a pleasant village, at the foot of New York’s Catskill Mountains, lives kindly Rip Van Winkle, a colonial British-American villager of Dutch ancestry. Van Winkle enjoys solitary activities in the wilderness, but he is also loved by all in town—especially the children, to whom he tells stories and gives toys. However, he tends to shirk hard work, to his nagging wife’s dismay, which has caused his home and farm to fall into disarray. One winter day, to escape his wife’s nagging, Van Winkle wanders up the mountains with his dog, Wolf. As the story goes, he was given moonshine by the ghosts of Henry Hudson’s crew and slept for 20 years through the hardships, stress, and anxiety of the American Revolution.
To understand Rip Van Winkle Syndrome as a metaphor for social anxiety (2)and social avoidance it’s imperative to be clear about the variations in today’s world which are the equivalent of the moonshine that enabled Rip’s sleep. Also; keep in mind that when anxiety causes avoidance a phobia is present. When social anxiety creates avoidance social phobia is present!
Countless times when parents of dependents ages 16, 26, and 36 initiate treatment they communicate to me “We would have done something but we didn’t know what to do”. The result of this parenting confusion is “enabling”, which resulted in the child’s developmental and accruing social avoidance. This statement is not a knock on parents. It’s a fact about an insidious and very misunderstood anxiety disorder; social anxiety. Please be very clear. Adults with pervasive social anxiety and social avoidance rarely initiate treatment. They are stuck in the homeostasis of primitive functioning which is driven by the avoidance-dependence syndrome. For the most part the psychotherapy community does not understand this syndrome.
I am defining “primitive” as spending the least amount of energy possible to sustain baseline functioning. The primitive homeostasis is the default which characterizes the dependent’s lifestyle. The dependent learns that avoidance is better than experiencing the pain of social anxiety.
Let’s consider the moonshine which enabled Rip’s sleep. Patient X was an intelligent 26 year old a college grad with no social life, except one friend. He had no job. He played 70-80 hrs of video games a week. In the beginning stage of treatment he said to me “I wouldn’t know what else to do with my time” (other than video games). Video games became the anesthesia that enabled him to avoid the stress of life. It was his moonshine. Upon initiation of treatment this was his lifestyle for 5years. Not quite Rip’s 20 but on the way!
Patient Y is also 26. He has a very similar profile. Add to it binge drinking on the weekend and an involved relationship with marijuana. More moonshine. Y did have a group of friends he maintained since high school. The current relationship was totally based on weekend drinking.
Patient Z was an attractive 23 year old female. Her mom initiated treatment after watching The Bing Bang Theory on TV and identifying her daughter’s problem as selective mutism; the same as Raj on the show. Selective mutism is a variation of obsessive compulsive disorder. In essence; it’s a speaking phobia. Although very attractive and athletic, and a member of the college’s elite sailing team Z could not socialize without alcohol in college. In addition she experienced major anxiety in situations that required verbal performance and critical thinking without being dependent on mother.
XYZ are examples of hundreds and hundreds of the approximately 10,000 individuals with social anxiety with whom I have worked since 1978. If you are concerned about an individual with a similar profile understand that because of the social anxiety induced pain the sufferer chooses social avoidance rather than embracing interactive life. Sadly, such sufferers mistake true pleasure for the avoidance of social anxiety . The avoidance becomes a compulsion or addiction.
As Rip Van Winkle avoided the stress of life with moonshine, the adult with advanced social phobia escapes stress and anxiety via enabling and various dependencies. Therefore; if you relate to this article as an enabler, understand that in order to be good at avoidance you also have to be good at being dependent. You have the leverage to empower. What you need is a strategy.
“Debbie” is a 24 year old athletic blond with hundreds of young men pursuing her on a dating site. She is currently getting her Masters in Special Education. Her mother initiated treatment after Debbie experienced a stress breakdown at the beginning of graduate school. Because of the anxiety episode Debbie withdrew from school for a semester. While Debbie had always struggled with performance anxiety and an auditory processing deficit, no one pinpointed the selective mutism until mother and daughter were watching “The Bing Bang Theory” on television and identified with Raj, who had selective mutism.
In treatment Debbie was making progress with her social anxiety. She resumed her education and was functioning well at school. She was expressing herself well in classes. She started to reconnect with friends she had been avoiding for a long time. She controlled her relationship with alcohol, which had been characterized by binge drinking to get her through social situations. She started to date. This was especially important as she had been in a co-dependent relationship for a number of years.
Recently she shared a story. She got into a young man’s car after a first date. At one point this young man became too physically aggressive forcing Debbie to leave the car. In session I asked her how long she had been “talking” to this person via telephone. She responded; “a couple of weeks”. I asked “when you were talking with him did you get any read on chemistry”? At that point she explained that talking over the phone meant texting.
This is an insidious example of how avoidance of speaking on the phone, which was a symptom of her selective mutism, lead to over-dependence on texting. This resulted in no opportunity for a read on social chemistry, and a potential problem that luckily was averted.
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If you were walking down the street and you encountered a saber tooth tiger your fight or flight response would be activated. Every human being experiences the phenomenon of fight or flight. Fight or flight is driven by adrenaline. The social anxiety sufferer of any age experiences fight or flight upon interactive or social challenges. Fight or flight, when not controlled, creates panic. Fear of experiencing the adrenaline of flight or fight can create avoidance. Interactive avoidance caused by anxiety is a social phobia.
Common social anxiety scenarios that activate fight or flight include public speaking in formal situations, speaking in public in informal scenarios, fear of being noticeably nervous as in blushing, sweating, or voice stammering, interacting with an authority figure, socializing in general and so on. The common denominator is the fear of being judged.
The adrenaline control technique will help you control the fight or fight response and panic attacks.
Let’s go through the steps.
Step # 1. Have realistic expectations.
This means that your adrenaline will be present when experiencing the challenging situation. Let go of any hope or wish that the adrenaline will not be present. This reality is a crucial component of the physiology of performance. Here’s an example. I’ve done well over a thousand television and radio shows during my career; every kind of show possible; from “Opra” to “Opie and Anthony”. Now I like doing them for many reasons, but an interesting phenomenon always occurs. Approximate 30 or so minutes before a performance my hands get cold. This is vaso-constriction. It’s a build- up of anticipatory energy. I am not nervous. I’m anticipating. It’s adrenaline-driven energy waiting to be released. To me it means “ready set go” as I accept its presence with the interpretation that the adrenaline is my friend and source of energy. “Ready set go” is the opposite, or paradox, of the negative thinking that creates panic. Your adrenaline is going to be there. It’s a fact! It’s an integral force of the flight or fight response which every human being experiences. The paradox of embracing the adrenaline will create power instead of panic!
Step # 2. Accept the adrenaline.
This is the hardest. As I just said, it’s a paradoxical concept. Paradoxical means opposite. It’s a good bet that this is a totally different mind-set for you. Accept the adrenaline with the interpretation that it is your friend and source of power. Identify the very first sensation that you experience when you know that a adrenaline will occur–the very first physical or mental sensation that you experience. Please answer the question now. It’s at this point that your internal critical script usually kicks in with thoughts to yourself like “oh no”,” this is bad”, “I’ve got to get out of here”, and so on. It is at this point that you need to replace the critical thinking with acceptance. In order to make a change you need to be clear on the first sensation or symptom of distress. I’m certainly not saying this change is easy. You’ve probably been conditioned for the negative script for a long time. What I am saying is that replacing the negative with acceptance can be profoundly powerful. Learning his skill takes practice!
Step #3. Surf the wave.
In your mind’s eye create the image of a surfer surfing a wave. Your adrenaline is the wave. In order to achieve a successful ride the surfer goes with the wave. The wave is power. The wave is analogous to the adrenaline. Go with it and you will harness its energy and power. Going with it requires embracing the reality that it will be there. You have a choice. Acceptance it’s power by going with the wave and surfing it or.. Don’t go with it. Don’t accept it and the wave will smash you around; you will fall of the surfboard. Falling off the board is the equivalent of uncontrolled panic.
Step #4. 1 or 2 diaphragmatic breaths.
It’s one thing to know the steps conceptually. It’s another to implement them. This is where skills acquisition and you’re learning curve come into play. The productivity of your skills development will directly be related to proactive thinking and behavior. This is quarterbacking or piloting. In other words; the more you seek out adrenaline opportunities the more you will have the chance for to learn the skill. Passive thinking and defensive behavior will inhibit the learning process and basically get you nowhere. You are going to need to experiment in order to learn a new skill!
In 1976 fresh out of graduate school I was working as a youth worker in a community center. A colleague, with a background in special ed., suggested that we start a socialization group for teenagers with learning disabilities. I had no idea what she was talking about, but we conducted research and discovered there was no such service being offered. We set up a program where applicants would come for an intake interview with parents before participating in the group. An interesting thing happened. Many of the clients interviewed never showed up for the group. This is how I discovered social anxiety in the late 1970’s.
In 1978 I started a private practice specializing in biofeedback for stress related disorders. Soon thereafter I integrated therapy for socially challenged individuals as a specialty. This was the beginning of my clinical experience 37 years ago. Since then; I have facilitated treatment for thousands of individuals of all ages with social anxiety and related disorders. Treatment has included individual, family, parenting, and group therapy. The functioning level of patients has varied tremendously. I have worked with many superstars in their professions as well as pervasively challenged individuals.
I want to share with you what I have learned regarding treatment efficacy!
First; in a private practice setting if you do not help your patients achieve their goals they will not come to therapy. Secondly; given that social anxiety is the quintessential disease of resistance, a creative and productive approach to treatment was necessary for productivity. The result was the Berent Methodology, which has been crafted, developed, and organized for 37 years.
The Berent Method has customized a treatment methodology adapted to the specific needs of social anxiety rather than fit the problem into the confines of existing modalities. This is the most important concept of this essay. The Berent model has integrated various functional psychotherapeutic modalities into it’s’ system as important tools for learning.
The starting point of treatment for social anxiety is to understand that while there are many manifestations of social anxiety there are 2 basic types of people with the problem. The 2 types are Individuals with “initiative, and individuals without “initiative”. Initiative does not mean ability it means the motivation to start up. I have not seen this variable factored into any formal research that demonstrates clinical efficacy.
For example, there is a substantial difference between the 26 year old who is experiencing relationship challenges and performance anxiety at work who initiates treatment independently vs. the 26 year old who is holed up in his room playing 100 hrs. of computer games a week and the parent initiates therapy . The fact that mental health technologies have not differentiated between the 2 basic subgroups (initiative vs non-initiative ) is a major component of the trivializing of social anxiety.
The term “evidence based” is often used for clinical marketing. The problem is that most evidence for social anxiety treatment success is quite limited. If you are going to take advice from someone it’s good to have evidence of that person’s performance. I encourage you to experience real evidence by accessing the free library of clinical interviews at www.socialanxiety.com. In fact, I challenge any therapist, hospital, university, or organization to come up with more evidence of clinical success for social anxiety!
The biggest confusion that people bring into treatment is a lack of understanding about how ingrained the problem can be. In order to understand “ingrained” it’s important to understand the architecture of the disorder.
The problem is multi-dimensional. It includes the following domains:
F. Function = physiology
A. Action = behavior
T. Thinking = cognition
Integrating FATE into treatment is essential if the objective is to resolve the core issues and to develop a “high performance mind”, which I define as proactive energy to achieve happiness and health. The two dynamics that are most absent from treatments in general for social anxiety are an understanding of the relationship of emotion to physiology and the avoidance-dependence syndrome that impacts individuals without initiative.
When my first book “Beyond Shyness” was published in 1992 by Simon & Schuster I had experienced a number of rejections by publishers. They had asked “you are writing a book about shyness why are you writing about parents”. My writing about parents was a sign that I developed a strategy to negotiate the avoidance-dependence pathology. This pathology can run very deep and is often the core of resistance. Avoidance often evolves into a compulsion or addiction.
I have been criticized by a few individuals for not having compassion for social anxiety sufferers. These people are incorrect. What they are witnessing is my energy needed to negotiate narcissistic-driven avoidance. I will discuss more on this personality dynamic at another time. At the risk of creating controversy I will tell you that too much compassion is an ingredient for the chemistry of enabling.
The philosophy behind the Berent Method is that time is your most valuable asset. Time is not elastic. It doesn’t stretch. Social anxiety accrues with time. The negative and painful mind-body response of social anxiety gets worse the more it remains the same. The average age of my patients since 1978 has been in the late 20’s. It’s extremely gratifying to work with young children as there is an opportunity to prevent the anxiety from becoming avoidant or dependent personality disorders. While the anxiety response can be very ingrained at age six, It’s much less than 26, 36 46 or 56.
Let’s first consider social anxiety without initiative. All children and most teenagers with social anxiety do not have initiative. Common examples include selective mutism, school phobia, and teenagers and adults who are pervasively avoidant and dependent.
Where initiative is not present treatment is parent focused. The goal is to empower vs enable. Parents are guided into parenting team building and teaching the dependent emotional intelligence. The concept of nurturing, which had been defined as rescuing, is re-architected into providing support and promoting growth. A crucial component of treatment is helping parents negotiate their own emotions and anxiety through the process. Adolescents and adults are integrated into therapy sessions after parents have learned appropriate skills. In the case of young children treatment is totally parent focused.
Now let’s consider treatment for social anxiety patients with initiative. Treatment is a combination of technique and core work. After a comprehensive orientation and history taking individuals are introduced to the concept of mind states. Based on the psychology of transactional analysis mind states is a productive tool in making concrete the therapeutic process. You can see that the therapeutic objective is to increase the “nurturing parent”, “adult” and “natural child” while decreasing the “critical parent” and “adapted child”.
The primary technique in the Berent model is the paradox of making friends with adrenaline. This requires a historical analysis of how the negative association to adrenaline was learned. This is concurrent with learning to accept and surf the wave of adrenaline. This technique will help to channel and harness the energy of adrenaline. Skills are implemented developmentally and are applied to the patient’s behavioral hierarchy of anxiety. This is where there is potential for immersion as a component of the behavioral strategy
Core work is based on The Sarno Method. John Sarno MD is world renown for his work with back pain and the “Mindbody Prescription”. The basic Sarno dynamic is that repressed anger and rage is the root cause of physical symptoms. This rage is so strong that it inhibits the flow of oxygen into the blood stream. This methodology facilitates an understanding of one’s “reservoir” (the unconscious memories). In the reservoir are the root causes of shame, embarrassment, and humiliation. Once the reservoir has been identified the goal is to attach on an emotional vs intellectual level. In mind state transactional analysis language the more that the natural child has not been nurtured, the more repressed rage there will be!
One of the questions you are probably asking is “how long does treatment take”? The answer depends on ones learning curve. The primary variables to the learning curve include length of the problem, severity of the problem, degree of obsessive energy, motivation, expressive ability, the ability to integrate new concepts, and readiness to face fear.
Pharmaceutical intervention is utilized when indicated. When used; the philosophy is to use the medicine as a tool to help facilitate the therapeutic process.
Since 1978 I have been developing an integrated therapeutic methodology to address the specific needs of social anxiety sufferers. This process has been the exact opposite of trying to fit social anxiety into the narrow confines of one already existing therapeutic modality.
Approximately fifteen years ago I integrated the work of John E. Sarno into my treatment architecture.. It has demonstrated remarkable clinical results! John E. Sarno, MD is world renowned for his work with pain. His treatment methodology for pain and a condition he identifies as Tension Myositis Syndrome (TMS) is based on the dynamic of bringing repressed anger and rage to a conscious level. This repressed anger is so powerful that it inhibits the flow of oxygen into the bloodstream creating pain. The connection of emotion to physiology has profound implications for treatment efficacy. I have discovered in my treatment of thousands of anxiety sufferers that the same dynamic is not only at play, but is in fact a core etiology.
Consider the psycho-physiological (mind-body) component of social and performance anxiety. Non acceptance, and anger, as a response to adrenaline exacerbates nervous system activity, which drives adrenaline, which causes panic. This is the physiological component of social and performance anxiety. The unrealistic expectations of perfectionism, which is a symptom of insecurity and a component of Obsessive Compulsive Personality Disorder, are major investments in the anger and rage associated with challenged self-esteem. In other words, when one’s internal critical script delivers unrealistic and toxic messages to the” inner child” (emotions) the result is anger, rage, emotional pain, sadness, fear and feelings of unworthiness in the unconscious mind. These emotions are driven by the sustained and obsessive unrealistic inner critical script. This is the emotional and cognitive component of social and performance anxiety.
Please do not confuse this psycho-physiological explanation, which includes physiological, emotional, cognitive, and behavioral variables, with the grossly generalized and over-used cliché of cognitive behavioral therapy (CBT) as it is applied to social anxiety treatment.
A visual of mind state dynamics can provide insight into what I am addressing. Please click here to view “Before” and “After” ego-graphs. Mind state work is based on the psychology of Transactional Analysis. The key point of these visuals is to view (1) the unbalanced condition in which the excessive internal “critical parent” mind state drives the excessive emotion and behavior of the “adapted child” mind state and (2) the balanced condition in which the excessive influence of the critical parent and adapted child are mitigated by increasing the “nurturing parent”, “adult”, and “natural child” mind states.
It is crucial to understand that, when it comes to social anxiety, mastering a coping technique is not a “cure”. Technique can be a major factor of controlling autonomic hypersensitivity and adrenaline, but without doing the underlying emotional work which Sarno describes as in one’s “reservoir”, treatment will quickly reach the point of diminishing returns. Technique concurrent with core work is the only answer for true resolution of the problem. The beauty of The Sarno Method is that is organizes relevant content in a highly efficient manner.
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.