The diagnostic category was formulated relatively recently and appeared for the first time only in the third version of the DSM, although its individual features are traced in the descriptions of old authors. To some extent, anxiety personality disorder resembles a sensitive type of psychopathy – not always distinguished in Russian classifications and attributable to variants of either schizoid or asthenic types.
Epidemiology. Data on the prevalence of the disorder, the ratio of patients by gender and genetic predisposition are absent. Patients already in early childhood are described as being overly timid and shy.
Clinic. Patients with anxiety personality disorder in everyday life are usually considered endowed with an inferiority complex. Their main feature is introversion , based on low self-esteem. In principle, they are not asocial and have a great need for social contacts, in order to participate in which they need unrealistically inflated reliable guarantees of unconditionally positive and uncritical acceptance by those around them. The slightest deviation of the behavior of others from the idealized representation of the attitude toward oneself is perceived as a degrading rejection . His fear forms a pattern of communicative behavior specific to these patients: stiffness, unnaturalness, uncertainty, excessive modesty, lowered prosperity, or demonstrative avoidance. In the intended rejecting others the patient is confident and considers it to be a sufficient excuse for his avoidance behavior.
Patients usually distort their attitude towards themselves, exaggerating its negativity. Nevertheless, it should be borne in mind that, due to the low level of communication skills, their objective awkwardness in social situations may cause reactions of others, indeed confirming their gloomy assumptions. Exaggerated not only the negative attitude of others, but in general the risk and danger of everyday life. It’s hard for them to speak in public or just turn to someone. In a professional career, they do not reach responsible positions, remaining unobtrusive, always ready to serve.Friendly, trusting relationships with someone may be completely absent.
In a conversation with a doctor, the mandatory initial tension of patients with anxiety personality disorder is strongly dependent on their feelings, how much they liked the doctor, determining their further behavior in contact. In general, it’s rather worth talking not so much about the desire to be accepted by others, but about fears of ridicule, bad gossip and gossip about yourself (excessive suspiciousness in this regard). A simple clarification or interpretation they may perceive as a criticism.
The course of anxiety personality disorder depends on what social “niche” they manage to occupy. The emergence of a matrimonial partner, corresponding to the patient’s ideal ideas about accepting oneself, can form stable relationships in which the patient’s entire social life is limited to the family. Disruption of social support may result in anxiety-depressive, dysphoric symptoms. High comorbidity with social phobia.
Diagnosis. In order to diagnose anxiety personality disorder, the patient’s condition, in addition to the common personality disorder (F60), must correspond to at least four of the following qualities or behavioral stereotypes: 1) a persistent, global sense of tension and concern; 2) conviction in their social awkwardness, unattractiveness or low value in comparison with others; 3) increased concern for criticism or rejection in social situations; 4) unwillingness to enter into a relationship without a guarantee to please; 5) limited lifestyle due to the need for physical security; 6) evasion of professional or social activities associated with intensive interpersonal contacts, for fear of criticism, disapproval or rejection .
Differential diagnosis. Evasion from social activity is characteristic of both the schizoid and anxious type, but the schizoid patient is characterized by a desire to stay alone and a matt affect, while anxious one is a desire to communicate, insecurity and fear. The clinical pictures of anxious and dependent types are very similar, but with anxious personality disorder, communication difficulties manifest themselves in the fear of making contact, in the dependent – in the fear of separation. A more reliable distinction between these types should be the task of subsequent versions of the ICD.The borderline and hysterical type distinguish from the disturbing manipulative tendencies, irritability and unpredictability of behavior characteristic of this patient . The distinction between anxious personality type and the spectrum of anxiety disorders is a problem similar to the distinction between the borderline type and the spectrum of affective disorders, and the schizotypical one from the schizophrenia group. Differences in the statics of a state can be quantitative, turning into a qualitative one when assessing the dynamics of a state.
Treatment. The method of choice is an integrative model, an individualized program, including psychodynamic and cognitive- behavioral techniques. Psychodynamic techniques explore the biographical formation of low self-esteem, cognitive- behavioral help the patient to realize the distortion of expectations to others and improve communication skills. Very effective here are group programs of communication skills, training self-affirming behavior. The most crucial part of the program is to consolidate the structural personality changes achieved during the course of treatment, in real communication outside the therapeutic situation. Here it is important that possible failures do not inflict further damage to the patient’s self-esteem, and the success achieved would make the communicative behavior self-sustaining .
Organic Anxiety Disorder
A number of factors can serve as etiological agents: various kinds of organic brain damage, CNS stimulants, paradoxical reactions to certain drugs (for example, atropine, scopolamine ), thyroid and parathyroid pathology, vitamin B12 deficiency, pheochromocytoma (due to increased release of CNS stimulator epinephrine ), pathology of the cardiovascular system, hypoglycemia, etc.
Clinic and diagnosis. Clinical manifestations are qualitatively identical to those in treating phobic disorders . The severity of anxiety can significantly impede social adjustment. Decisive for diagnosis is the detection of an organic etiological factor that causes anxiety as a secondary manifestation.Organic anxiety disorder is diagnosed when the condition meets the general criteria of F06, as well as the criteria for anxiety and phobic disorders (F41.0, F41.1). For differential diagnostics with anxiety states of other genesis, it is important to establish how closely the symptoms of anxiety in the clinical picture are related to the primary organic factor.
Treatment. The main effect is on the etiological organic factor. Symptomatically used anxiolytics , behavioral therapy. In the treatment of obsessive manifestations in some cases, antidepressants are used. In case of irreversible, pharmacologically resistant states ( obsessive- phobic syndromes after encephalitis are prognostically most adverse ), psychosurgical interventions are possible . In some cases, the elimination of the etiological factor may not be accompanied by an immediate relief of anxiety symptoms.