What is Avoidant Personality Disorder?
Avoidant Personality Disorder (AVPD) refers to a consistent pattern of intense social anxiety, extreme sensitivity to criticism or rejection, and overwhelming feelings of being inadequate. At the same time, those with AVPD crave meaningful relationships with others. The first time AVPD was described was in 1911 by a Swiss psychiatrist named Eugen Bleuler, and it was later further distinguished from schizoid personality types in 1921 by German psychiatrist Ernst Kretschmer. This disorder was formally recognized in the 1980 Diagnostic and Statistical Manual of Mental Disorders (DSM).
Some people have debated the similarities between AVPD and social anxiety disorder. Personality disorders, according to the DSM, are categorized into three groups or ‘clusters’: Cluster A, Cluster B, and Cluster C. Each cluster gathers disorders that share similarities in symptoms, behaviors, and psychological patterns.
Cluster A includes odd or eccentric behavior-related disorders such as paranoid, schizoid, and schizotypal personality disorders. Individuals in this cluster often have social anxiety, unusual or paranoid beliefs, and find it difficult to form close relationships.
Cluster B consists of disorders associated with dramatic, emotional or erratic behaviors like antisocial, borderline, histrionic, and narcissistic personality disorders. Individuals in this cluster usually show spontaneous behaviors, emotional instability, and face challenges in maintaining steady relationships.
Cluster C features disorders characterized by anxiety and fear, including avoidant, dependent, and obsessive-compulsive personality disorders. Individuals in this category often feel high levels of anxiety, fear of being abandoned, and an excessive need for control and perfection.
However, it’s important to mention that the ‘Cluster’ system used for classifying personality disorders has its limitations, and it’s not always supported by scientific literature.
What Causes Avoidant Personality Disorder?
Research on the causes of Avoidant Personality Disorder (AVPD) is still pretty scarce, and there isn’t a clear consensus on what exactly causes this condition. It’s thought that a mix of genetics, childhood experiences, and environmental factors might play a part in it. However, these factors remain the topic of investigation and debate.
Studies using twins have proposed that AVPD may be hereditary, meaning that genetics could make someone more prone to this disorder. Still, the exact genes or genetic processes involved in AVPD are not yet fully understood.
Brain-related health issues, including head injuries, stroke, brain tumors, epilepsy, Huntington’s disease, Multiple sclerosis, certain hormone disorders, heavy metal poisoning, a very late stage of syphilis, and HIV/AIDS often go hand in hand with personality disorders or changes.
The development of personality traits and disorders rely on several factors such as unconscious processes, early childhood experiences, and internal conflicts. Wilhelm Reich, a psychoanalyst, introduced the idea of “character armor.” It’s a defense mechanism that people develop to deal with internal conflicts and anxiety. As an example, people with avoidant traits often use withdrawal as a defense mechanism.
According to object relations theory, avoidant behaviors might stem from attachment problems in infancy, leading to a strong fear of intimacy. People with AVPD often live in a world of fantasy and have imaginary friends who give them internal satisfaction. Early interactions with caregivers and any trauma or neglect experienced at an early age can contribute to the development of AVPD.
Our personalities are a unique mixture of biological, psychological, social, and developmental factors. Therefore, every person’s personality is unique, even those with a personality disorder. Personality refers to the ways people uniquely adapt and behave in response to constant changes in their inner and outer worlds. This includes factors like temperament, which are inherited traits that can further be shaped by life experiences such as trauma or socio-economic conditions.
Examples of temperament traits include harm avoidance, novelty seeking, reward dependence, and persistence.
People with AVPD often display very high “harm avoidance,” meaning they avoid actions that could lead to rejection or emotional harm.
“Novelty seeking” refers to a desire to seek out new experiences that may be rewarding, but individuals with AVPD tend to have low novelty-seeking behavior.
“Reward dependence” describes the degree to which a person’s behavior is influenced by social reward cues. People with AVPD generally have low to moderate reward dependence, which means they may have difficulty forming satisfying relationships.
“Persistence” refers to the ability to continue efforts despite challenges or obstacles. Those with AVPD often show less persistence and can quickly give up when they encounter obstacles.
Risk Factors and Frequency for Avoidant Personality Disorder
High-quality studies about Avoidant Personality Disorder (AVPD) are few and the existing ones are outdated, meaning they come from an era when the Diagnostic and Statistical Manual of Mental Disorders (DSM) used different criteria for diagnosing mental conditions. This makes the application of these studies limited.
- One study used data from the 2001-2002 National Survey on Alcohol and Related Conditions, which had 43,093 participants, and estimated that about 2.36% of the population has AVPD.
- Another study from the same period (DSM-IV era) looked at 270 psychiatric outpatients and found that approximately 14.7% had AVPD.
Signs and Symptoms of Avoidant Personality Disorder
Avoidant Personality Disorder (AVPD) is a condition that often varies in how it shows up in different people. Therefore, understanding a person’s full medical, emotional and social history is crucial. Individuals with AVPD are usually shy, and it’s often up to their family members to push for them to get a psychiatric evaluation. A common trait of AVPD is being highly sensitive to rejection, even though they crave meaningful relationships with others. This fear of rejection often leads to them avoiding social interactions entirely, becoming intensely introverted.
When conversing, individuals with AVPD often lack self-confidence and might speak in a self-demeaning way. They may wait for permission from a family member to express themselves, due to the fear of being rejected by their doctor or therapist. These people can frequently misinterpret any comments about them as insults or ridicule. Therapists and doctors working with individuals with AVPD need to be patient, supportive and non-judgmental, creating a safe environment in which the person can express their thoughts and feelings freely.
People with AVPD often struggle to secure a job, but when they do, it’s usually in non-challenging roles or part-time positions. They generally only start romantic relationships if they’re highly confident they won’t be criticized or rejected. This fear of rejection also affects their friendships, limiting their capacity to build or maintain relationships with friends and extended family members.
During a psychiatric evaluation, a mental status examination plays a key role in assessing individuals with AVPD. It’s important to note that certain elements and findings can vary. Therapists should consider the following aspects when assessing patients:
- Appearance: Pay attention to their grooming and fashion choices. They often prefer neutral clothing to avoid attracting attention or criticism.
- Behavior: Notice any signs of nervous behavior, averted gaze or difficulty maintaining eye contact. Their cooperation might also vary based on whether they feel accepted by the clinician.
- Speech: Individuals with AVPD may speak less due to their shyness, but there should be no issues with speech initiation, loudness, or vocabulary.
- Affect: They typically show signs of anxiety or stress, especially during uncomfortable clinical evaluations.
- Thought content: Their thoughts usually revolve around fear of being disliked, but these are not usually delusional or obsessive.
- Thought process: Their thought process is linear but often limited and influenced by their fear of judgment.
- Cognition: In general, people with AVPD have no issues with cognition and orientation.
- Judgment: They often have poor judgment, as their unfounded fear of rejection hinders their ability to make rational decisions.
Testing for Avoidant Personality Disorder
Establishing a diagnosis for a personality disorder generally requires a comprehensive analysis of a person’s behaviour across different circumstances over a longer period of time. This approach provides a wide-ranging understanding of their long-term behaviour. Some behaviours seen in personality disorders can also be present in other severe mental health conditions. As such, personality disorders are typically diagnosed when there are no other current severe mental health issues.
However, in some situations, it’s not always feasible or necessary to review a person’s behaviours over long periods. This is particularly true when the personality disorder significantly contributes to repeated hospital admissions or the reoccurrence of another mental health condition like a major depressive episode. Thus, it might take multiple patient visits to definitively diagnose Avoidant Personality Disorder (AVPD).
A formal diagnosis of AVPD requires meeting certain criteria set forth in the DSM-5-TR, a manual mental health professionals use for diagnosis. The diagnosis process includes a thorough assessment that involves reviewing personal history, gathering information from other sources and a mental health examination. This comprehensive approach allows healthcare providers to evaluate the individual’s symptoms, behaviour and overall mental health in relation to the diagnostic criteria for AVPD.
In order for a diagnosis of AVPD to be made according to DSM-5-TR criteria, individuals must display persistent patterns of social inhibition, self-perceived inadequacy and hypersensitivity to criticism in various contexts. This pattern should start in early adulthood and lead to significant problems in social or work situations, or other important aspects of life. The person should also exhibit at least four of these specific behaviours:
- Avoidance of social, professional, and interpersonal activities out of fear of being criticised, disapproved or rejected.
- Resistance to forming new relationships unless there’s a guarantee of being accepted.
- Reluctance in developing intimate relationships due to fear being laughed at or embarrassed.
- An obsession with criticism and rejection.
- Inhibition in unfamiliar social situations due to feelings of inadequacy.
- Low self-esteem with a belief that they are unattractive or inferior to others.
- Avoidance of taking personal risks or participating in potentially embarrassing activities.
Treatment Options for Avoidant Personality Disorder
Research into the best ways to manage Avoidant Personality Disorder (AVPD) is currently limited. The majority of studies are from specific case reports or focused on treatments for social anxiety disorder. Many of these studies have not shown success in treating AVPD and report low rates of symptom improvement and inability to reach regular levels of functioning.
Various types of psychotherapy, like cognitive-behavioral therapy (CBT), have been tested for treating AVPD. CBT is considered the best treatment option for AVPD and aims to change negative thinking patterns, improve self-confidence, better social skills, and challenge behaviors that avoid and evade. However, CBT has shown limited success.
Exposure therapy, a type of cognitive-behavioral therapy, showed some success for treating social phobias but had a high drop-out rate. Approaches like ‘mentalization’ and interpersonal therapy also showed some effectiveness in treating AVPD. As AVPD is unlikely to improve with or without treatment, treatment may focus on reducing stress in personal relationships and improving socioeconomic conditions.
Generally, psychiatric medications aren’t effective in treating AVPD, and there are currently no FDA-approved drugs for this condition. Drugs that modulate serotonin, like selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), may work well for social anxiety disorder. However, there is limited evidence that these drugs can also help AVPD. But treating other conditions that occur alongside AVPD with psychiatric medication could likely reduce the suffering in patients with AVPD.
What else can Avoidant Personality Disorder be?
Avoidant Personality Disorder (AVPD) is often confused with Social Anxiety Disorder (SAD) due to the similarities in their symptoms, causes, effects on one’s quality of life, and general symptoms. Some scholars argue that the two disorders may exist on a range, with SAD as a less severe condition and AVPD as a more severe form. AVPD tends to have a more significant impact on social and job performance than SAD. However, the American Psychiatric Association asserts these are two separate disorders, since roughly two-thirds of those with AVPD do not meet the criteria for SAD. SAD usually presents as anxiety related to specific situations rather than a general fear of interpersonal contact, as seen in AVPD. Both disorders can be present in a person if they meet the criteria for both. Other anxiety disorders, like agoraphobia and panic disorder, can also co-exist with these conditions.
Despite sharing similarities with Cluster C personality disorders, which include fear and anxiety, AVPD differs from dependent personality disorder. While people with dependent personality disorder are anxious and desiring closeness due to fear of separation from a loved one, people with AVPD constantly worry about being rejected. While AVPD and schizoid personality disorder both result in social isolation, the reasoning behind the isolation differs. People with AVPD actively avoid social situations to evade rejection, while those with Schizoid personality disorder demonstrate passive detachment due to a total lack of interest in socializing. Furthermore, those with schizoid personality disorder are indifferent to rejection and social interaction.
What to expect with Avoidant Personality Disorder
Avoidant Personality Disorder (AVPD) is a long-term disorder that significantly affects a individuals’ ability to function socially and professionally. A study observed the stability of AVPD symptoms over two years and found that people with AVPD often show a high level of resistance to getting better. Some of these lasting symptoms include feelings of inadequacy, social awkwardness, and a constant need for reassurance before participating in social interactions.
However, not all is bleak. Some research suggests that over time and with the right treatment, some people diagnosed with AVPD may eventually stop showing the symptoms that initially led to their diagnosis. Specifically, one study estimated that about half of the individuals diagnosed with AVPD might no longer meet the diagnostic criteria after ten years.
Possible Complications When Diagnosed with Avoidant Personality Disorder
Substance abuse problems are often seen in individuals suffering from personality disorders. However, it’s not exactly clear which specific personality disorder tends to increase the risk of developing a particular substance use disorder. Personality disorders also tend to increase the likelihood of suicidal tendencies or attempts compared to individuals without such disorders. In particular, those with Narcissistic Personality Disorder (NPD) should undergo regular check-ups to detect any signs of suicidal thoughts.
Preventing Avoidant Personality Disorder
Treating Avoidant Personality Disorder (AVPD) mainly focuses on creating and maintaining a great relationship between the therapist and the patient. Therapists reassure patients that the treatment setting is safe and supportive. Patients are advised to openly discuss what symptoms they want to tackle and any life stresses they want help with. The goal is not so much to change how the patient views the world, but more so to understand and respond to the specific issues the patient is dealing with. This approach is especially useful when the patient is not in immediate distress or crisis when alone.
Additionally, the therapist suggests that patients make use of their existing social connections and try to grow these as they become more comfortable and confident. Involvement of the patient’s family can also be useful to spot any decline in mental health and to educate them on how they can provide a stable social atmosphere for the patient. Using standardized quality of life assessments can also point out approaches to improve significant areas of life for a person with AVPD.
