Kyle: Our producer said that you actually wanted to bring this topic to MedCircle? Why this topic? When we have…there’s probably hundreds of them…why this one?
Dr. Ramani: This is one of those patterns that’s not talked about by name. And yet it affects so many people and it affects their loved ones.
And they may not even know that this pattern is something that they could help alleviate through treatment. And so I think that like with so many things that once you realize that, the many people who are struggling with anything think this must just be me and I’m broken. And so one thing we’ve seen throughout MedCircle, and one of the beauties of MedCircle is people in the privacy of their home can watch something and it becomes an awakening, right?
And that’s what I hear from many people who view this, they say, you know what, this is the first time I ever thought of this. And I’ve now seen many people not only seek out help for themselves, but also their family members.
So this particular pattern is something that I’ve seen in my own clients. And they said, “You know what? I just thought I was super shy.” And I said, “Shy people aren’t uncomfortable.” I hate that. Shy is a bad word. It’s just simply so what if a person doesn’t wanna be interacting with people all the time? But avoidant personality is really about being afraid of rejection, about holding back, about being afraid of looking foolish.
That’s a different game. That’s a different game and there’s actually more and more interesting research coming out about what this thing really is so we can better understand it and then again, hopefully better treat it. But that’s why I brought it up.
Kyle: Really great reasons. I’ve experienced the same thing. I have the unique position of being the host at MedCircle and being a MedCircle member. Because I watch our series both as a member and as the host, and I’ve experienced those awakening moments whether it was a mental health diagnosis that I have where I’ve experienced an awakening or an understanding of a mental health diagnosis that I didn’t fully understand before. I think this series will offer that awakening to a lot of people.
Dr. Ramani: I think so. And it’s like, when does it stop being shyness or fear of public speaking and when does it start becoming something that is holding them back from living a fuller life? Nobody should feel lonely. We’re in a world full of people. I’d love to see that people can make those meaningful connections with other people and understand what are those impediments and help break that down.
Kyle: If the topic of loneliness is interesting to you, make sure you check out our episode with Dr. Sue Varma about the loneliness epidemic. We filmed that in New York. Truly fascinating and eye-opening. Make sure you check that out. Now, what causes APD?
Dr. Ramani: So when we look at avoidant personality disorder, the research is suggesting there’s probably multiple trajectories and it’s complicated.
There’s no one singular path, and it’s likely a combination of childhood environment, potential childhood adversity, parenting styles, attachment style, and some genetics. So all of that mixes together to generate this. Now there’s a lot of work here that looks a lot at early childhood environment and experiences.
For example, some of the researchers suggested that people who come from early environments that are characterized by lots of parental shaming, those folks are at greater risk for avoidant personality disorder.
Children who have highly avoidant or anxious attachment styles may be more likely to have avoidant personality disorder, and those attachment styles come from early environments characterized by chaos, trauma, inconsistency and abuse.
Those are the kinds of things that can feed those sorts of attachment styles.
But children who repeatedly kept getting those problematic social messages as a child and didn’t have parental help who often were rejected by their parents or maybe even made fun of children who were bullied mercilessly, not just by peers at school, but maybe even by siblings or other family members…that’s a setup for avoidant personality disorder.
So all of these things represent a lifelong trajectory of not only a social anxiety, but a fear. A fear of being rejected and then holding back because of their fear of social inadequacy. And there’s actually some really interesting research that even looks at these ideas around social cognition, the way we think about the world and we think about the people in it.
And I was just reading an article that had recently come out and they were talking about the concept of something called mentalization. And mentalization is how we think about the feelings and the motivations of other people because the motivations and the things we attach to other people’s behavior have a lot to do with how we interpret them.
So if you have more negative mentalization experiences, that might make you more socially anxious. If you keep thinking, everyone thinks you’re foolish or awkward or wrong, then that is going to be more of a downward drift into chronically having negative social experiences with the world.
So it’s like over time. And why would people have that mentalization experience? Because over the course of their life, that’s what they were told and that’s what they were reinforced or rewarded for. And kids who come from these early environments that are this…I don’t know…fear inducing about social stuff, what do they learn to do? What any of us would do. They withdraw.
They’re like, if I avoid these social situations, that would make my life a lot easier, wouldn’t it? Kids are quick. And the kids are like – forget it. I’m not doing this social thing. It just gets me hurt, it hurts my feelings. It doesn’t feel good.
And kids don’t like doing things that don’t feel good. So they pull out and then over time, they just learn that pulling out is the answer. So that’s really the combination of factors that gets a person there. And I have to say in the clients I’ve worked with over the years, the clients who had avoidant personality disorder, almost without exception, there was a lot of shame in their family of origin. “You’re such an idiot. Or, “Don’t make us look bad, or keep your mouth shut when we’re there, that kind of thing.”
Kyle: Go back to the attachment styles you were mentioning. What do those look like?
Dr. Ramani: So the critical research on attachment was originally done by Mary Ainsworth and John Bowlby, who set the tone for this developmental research years ago.
And what they did was they found that there were three standard attachment styles. The attachment style we like to see is the secure attachment in the securely attached child. They get a little upset when their primary caregiver drops them off somewhere, leaves them with a stranger. There’s a little bit of distress.
After the caregiver leaves they’re able to be soothed pretty quickly by the new caregiver. Like a daycare provider or something. And when that primary care caregiver comes back to pick them up, the child happily reunites with that person. So it’s a sense that I don’t like that you’re going but you’ve gone. And I’m gonna be okay because you’re inside of me. And then when you come back, I’m happy to see you. That’s what we’re going for. That’s secure.
Kyle: Hear that parents? That’s the goal. That’s the goal. All right.
Dr. Ramani: That’s the goal. The anxious attachment style is characterized by the child who, when dropped off from the parent, becomes very disorganized, very chaotic, cannot be soothed by the person that they’re dropped off to.
Then when the caregiver returns, the caregiver can’t soothe the child either, so they just can’t calm down. They can’t calm down. For example, in children, there’s even a pattern we call separation anxiety disorder. These are kids that do not soothe well when they’re separated from their caregiver.
One might say what’s the big deal? They really love their mom because pretty early on we need a self-soothing mechanism. That mechanism is that she’s gonna be back. She’s always been back.
Kyle (2): So when should we have that?
Dr. Ramani: That should pretty much have clicked into place solidly by two to three years of age.
Kyle: Ohhh. That is young.
Dr. Ramani: Young.
And I have to tell you as a mom, I remember this very well. And I had the blessing of both my daughters were in an amazing childcare facility where there were one way mirrors. I was a hot mess when I had to drop her off. So I would stand and watch at the glass.
I had a little timer. Both of my girls they actually soothed pretty quickly. I’d say within three to five minutes. They’re babies. There was just sunshine and I’m like…secure attachment!
Kyle (2): Yeahhhh! And you were the only mother who knew what was going on though?
Dr. Ramani: It was a bunch of psychologists’ kids. So everyone knew, but the fact was, it was that sense of, as a mom, you feel that too, right? Your baby’s crying. So I had this blessing that I could look in, and then I would only leave. After I saw that they had stopped crying.
And so were there days that went longer? Sure. And those were nights that they didn’t get enough sleep. There were other things going on, so I was aware of that. But that anxious style, that child should be able to reconstitute. They shouldn’t be so panicky that mom’s not, or caregiver’s not gonna come back.
And then when mom’s back, that inability to soothe in the presence of mom, when that plays out into adulthood, think about it.
You’re so anxious, you can’t even soothe yourself when you’re with the person you love. That sounds like a lot of the personality issues we’ve talked about on the MedCircle videos.
Kyle: But how would that develop into avoidant personality disorder?
Dr. Ramani: Because that person feels so anxious and unsafe, they can’t be soothed.
It makes you wonder how connected they are to that parent. Is there something chaotic in their attachment to that parent? So there’s almost like a lack of social confidence, even though it’s a little kid. But that’s where that plays out.
The avoidant personality, I’m sorry, the avoidant attachment style…it’s actually a bit more extreme. This is actually probably the most problematic. It’s where the child, when they’re dropped off, is almost indifferent. They’re like peace but not like nice peace.
There should be a little distress. Imagine just dropping your partner off at the airport for a three month visit. You’re like, bye, catch you on the other side. Yeah, I don’t know if that relationship’s working out. Similar with kids.
When you’re a small child and your primary caregiver’s dropping you off and that child doesn’t even look back twice, it makes you wonder what that attachment is. And many times then when the caregiver comes back to get the child out of that setting, the child doesn’t even look up and notice, they just get up and walk with them.
And that’s what we’ll often see in situations of neglect. So you can also see there’s not a lot of social infrastructure there for that child. So those more difficult attachment styles, particularly that anxious attachment style, is something that we may also see in a person with avoidant personality disorder.
Kyle: If a parent notices that their child is showing signs from the second one and the third one, and not that secure attachment from the ages of 2, 3, 4, 5, 6, 7, 8, 9, what can they do to start to get their kid in the right place?
Dr. Ramani: First of all when you’re seeing these issues with attachment…I don’t wanna ever pathologize parents.
There can be lots of reasons for this. Number one, if you’re having severe issues around, transfers to other caregivers or even transfers to, for example, a grandmother or someone who’s not the primary caregiver, pay attention to it and then consult with your pediatrician.
You wanna make sure that you get a proper workup for other developmental issues, including anything from Autism spectrum. There are other anxiety disorders we can see in younger children. I always want to make sure that parents err on the side of over insuring that they’ve addressed any of those issues.
You also wanna make sure though, that whatever place you’re putting them, is also safe. Your child’s negative reaction to being left there could also be that the place is someplace that they don’t feel comfortable. So you may wanna watch it and any childcare facility should definitely let you be able to keep an eye, especially for small children.
They should be able to let you watch that facility for a few days, if not longer, to make sure you feel comfortable. You wanna make sure you look at this from all angles.
Why is the child reacting? This is universal. It’s a child reacting, whether you leave them with someone familiar or at a childcare facility or anywhere. Or is this in a very specific locale? Because it could be something there. And then look at what’s happening in the home. Is there a lot of chaos in the home? Is a child able to get a good night’s sleep? Are there lots of disruptions in caregivers? Are there lots of people in and out?
So it really requires parents to be thinking about this in a very holistic way.
What’s happening in this environment? And does a parent need support? Let’s say you have a parent who’s really overwhelmed. They’re working, they’re struggling with other stuff. That means a lot of people with young children are living under a lot of stress. Sometimes that parent just needs a little bit more support to be able to support their child.
I think we expect parents to be super parents all the time. It’s a lot of work. It’s a lot of work to raise a child. And sometimes a parent just needs a little boost up. We all did. I did. Everyone does. And so to give yourself permission for that because that might also ease some of the parent’s anxiety, which will ease some of the child’s anxiety.
And then hold them a lot. Hold them a lot.
Some of that basic attachment stuff is baby stuff. Zero to 12. Hold them while you feed them. Put your phone down, stare them in the face. Hold them, touch them, play with them, laugh with them. Make sure lots of people smile at them. Talk to them.
It’s baby raising…0-1 kind of stuff. For some parents who may be struggling for any number of reasons, we can’t just write that off as easy.
Kyle: Of course.
Dr. Sportelli and I did a series on ADHD. He is a father of two boys or three boys maybe. And we were talking about his parenting styles. And he said, “I do the best I can and I think I’m a good enough parent.”
Dr. Ramani: That’s the word.
Kyle: And I said that’s so reassuring. Good enough.
Dr. Ramani: That comes from Winnicott’s work, who was a sort of a psychoanalytic theorist and developmental theorist who talked about the good enough parent. And in fact, we only need to be good enough. Our kids learn from our mistakes.
Every so often it takes us too long to come soothe them. That’s when they start learning to soothe themselves. We need to make just enough mistakes so they learn to do some stuff by themselves.
Kyle: Yes. Yes. I get that. What demographics are typically affected by APD?
Dr. Ramani: I think that we do see it pretty evenly between men and women. Like I said, we don’t have a lot of good prevalence data because it’s harder to do that kind of epidemiologic work, where we gather numbers on who has a disorder in, in things like personality disorders.
So my understanding, it’s pretty evenly distributed. Men and women, interestingly. And I think you might see, though, with avoidant personality disorder, upticks of this pattern in people who may for example, if there are any patterns, cultural patterns or otherwise where sort of parental shame might be more likely to happen.
I can’t even begin to spitball that because we live in such a diverse country, whether that’s regional, whether that’s racial, ethnic, whether that’s related to socioeconomic status. I think that can happen in all of those groups.
But anytime parental shame, rejection, even almost like familial bullying where like it’s a lot of mockery…I think a lot of people think that might be good family fun…NOT.
Because somebody with a vulnerable temperament who comes up against that rejecting, invalidating, familial style, that’s the kind of one-two punch that can culminate in this kind of a personality issue. So I do think that some of it is like also a stylistic issue within a family system.
Or family culture.
Kyle (2): What else do you want people to know about APD and the causes?
Dr. Ramani: With any of the personality disorders and certainly one like avoidant personality disorder, there’s lots of different paths to this.
Is there a genetic association? Absolutely.
But the challenge is is now you have a parent who’s more socially isolated so now you’re wondering, is this the child learning that social interactions are scary from their parent, or is it a frank genetic relationship?
These are the things that are really difficult to tease apart. There’s no gene for avoidant personality disorder. So these are often very complex, nuanced kinds of patterns. And because avoidance is really a behavior, right? Avoiding a situation. We need to ask why it is they’re avoiding it. And in avoidant personality, it really is that fear of rejection.
It’s that fear of inadequacy. And so we almost can work it backwards and that’s when I work with clients, I work that pattern backwards to figure out when did you start getting that message? Invariably that message started around right before elementary school.
It was that young, and for some of them it was also peers at school. This is why even school bullying is such a key mental health issue. Anybody who says, come on, it’s kids being kids. Absolutely not. It’s not kids being kids. The damage of that kind of bullying behavior in school is lifelong. It hurts people. It’s lifelong.
And I’ve worked with clients who even in their fifties and sixties still carry that, who still talk about those experiences they were defining. We spend a lot of our time in school as kids. And those kinds of experiences can definitely contribute to this. And when we think about sometimes the kinds of kids who are already targeted in that way, it just takes one group of vulnerabilities and it piles it on.
So from a policy level, we have to pay more attention to these patterns of kids being bullied. To this day. Now electronics have allowed a whole new form of that. How that’s gonna play out with avoidant pd, I don’t know, but I can’t think it’s gonna be good.
Kyle: I will leave it at this quick story.
I, for whatever reason was not bullied in school. As a gay boy, never bullied. I think I just got lucky. I was spared during that part of my life, but the first video I ever made and put up on YouTube, I was bullied digitally. And as an adult man, getting thousands of, “Go kill yourself. You’re terrible” messages a day, it debilitated me.
Dr. Ramani: Yep.
Kyle (2): Because I thought everyone was just nice. I just thought – of course people are nice. I had no idea that there were mean people…like that.
Dr. Ramani: And you were a full on adult when that happened…
Kyle (2): A full on adult!
Dr. Ramani: As someone who was bullied, I can tell you I was an incredibly socially inhibited person until well into college. And once I met this wonderful group of friends and I hope they’re watching so they know I’m talking about them, but this amazing group of friends who are still my closest and dearest, they celebrated the me who was me, and I slowly came out of it, but it was ruthless.
And even to this day, I find myself still somewhat inhibited and thinking like, do I really open my mouth? And I think of how many times I’ve held back. I talk for a living. And so these patterns last. It took me a while to even push back, even though I don’t think it was at this pervasive level, my feelings of inadequacy in social settings…
It’s also an intersection.
I’m a minority woman. The age I was growing up, that sense of inadequacy got magnified under that too. And so there’s so many things that operate at the same time for folks. That’s why we have to look at a client holistically, their experiences, where they are now, what they represent to the world.
Like you said, as a white gay male, it should have been open season on you. Thank goodness that didn’t happen to you. But when it does, I don’t care if you’re 50 or you’re five, it hurts. And yet bullying is worse than it’s ever been because of online spaces. Alot of people who would’ve bullied wouldn’t have done it because bullies are cowards, right? So they won’t do it to your face.
Now, anonymous bullying…I think it’s gone up a thousand fold. So I think we see this in young people who are in those online spaces.
Again, how that’s gonna affect avoidant pd…those numbers…it’s just gonna be time will tell. Time will tell.
