Avoidant Personality Disorder (AVPD) is characterized by avoidance of social interactions due to severe fear of rejection and feelings of inadequacy. AVPD impairs life function, with women appearing to be at slightly greater risk.6 Treatment using cognitive-behavior, schema, and psychodynamic therapies along with social skills training can help treat this disorder.6 Avoidant Personality Disorder is only diagnosed in adults.
What Is Personality?
To understand Avoidant Personality Disorder, it is helpful to understand the concept of personality. Personality is the sum of an individual’s overall biological, psychological, social learning, and their inherited genetic traits. In other words, personality establishes how one thinks, feels and behaves. Personality determines whether an individual can effectively live in and adapt to a changing world.2
What Is Avoidant Personality Disorder?
Individuals with Avoidant Personality Disorder constantly fear they will be rejected due to thinking that they are inferior to others. At the same time, they have an intense longing to be liked. A negative concept of self and deep-seated fear causes individuals with Avoidant Personality Disorder to avoid social interactions making it nearly impossible for them to form personal relationships. These characteristics impair all aspects of life.
Researchers focus on thoughts and behaviors of individuals with Avoidant Personality Disorder to test effective treatments for AVPD.
The following concepts help to explain Avoidant Personality Disorder:
- Mentalization. The ability to estimate the underlying wants, needs, intentions and goals of others that drive their behavior. Individuals with Avoidant Personality Disorder may lack mentalization causing lower self-esteem and poor social function.6
- Affect consciousness. The ability to be aware of, regulate and express emotions. Some individuals with Avoidant Personality Disorder avoid emotional expression to protect themselves from painful rejection, which can be interpreted as coldness by others.6
- Hyper Emotional Sensitivity. Being overly aware of others’ emotional states when one is expecting rejection intensifies fear, which is another reason to avoid social interactions.6
- Malignant Self-Regard. A pattern of disappointing others leads to a negative self-concept with aspects of shame, inability to express anger, depression and belief that one is inadequate overall.6
Signs of Avoidant Personality Disorder
Look for these characteristics to be prominent, consistent and extreme in Avoidant Personality Disorder:5,6
- Quick to make negative self-judgments
- Intense, sad and lonely
- Low self-esteem
- Hypersensitive to others’ emotions
- Emotionally avoidant
- Poor eye contact
- Blush or cry easily
- Aloof
- Fragile
- Skittish
- Quiet and inhibited
- Anxious
- Hypervigilant to threats
- Timid or shy
- Depressive
- Reluctant to talk about self
- Isolation
- Fear of embarrassment
- Fear of rejection or being dismissed
- Perfectionism
It is difficult to distinguish AVPD from Social Anxiety Disorder (SAD) due to overlapping characteristics. In earlier research, Avoidant Personality Disorder was thought to be a more severe form of social anxiety disorder, with both being placed on a social anxiety continuum. Recent research argues that they are different disorders due to genetics, differences in self-concept, negative thinking and treatability,5
Research has shown that all personality disorders are predictors of worse health outcomes, suicide risk, premature death and more serious life issues.4 Individuals with Avoidant Personality Disorder often manifest physical ailments, like chronic pain, colitis and eating disorders. Substance misuse is also common.4,5,6
Symptoms of Avoidant Personality Disorder
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) provides specific criteria for diagnosing Avoidant Personality Disorder.
DSM-5 criteria for Avoidant Personality Disorder includes a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as the individual displaying four (or more) of the following:
- Avoids occupational activities that involve substantial interpersonal contact because of fears of criticism, disapproval, or rejection
- Is unwilling to get involved with people unless certain of being liked
- Shows restraint within intimate relationships because of the fear of being shamed or ridiculed
- Is preoccupied with being criticized or rejected in normal social situations
- Is inhibited in new interpersonal situations because of feelings of inadequacy
- Views self as socially inept, personally unappealing, or inferior to others
- Is unusually reluctant to take personal risks or engage in any new activities because these steps may prove embarrassing.1
The DSM-5 provides an alternative model for diagnosing personality disorders, which measures impairments in personality function and pathological personality traits. This model takes into account the overlap of traits in the 10 personality disorders shown in the DSM-5. It also presents personality disorders on a spectrum instead of as discrete diagnoses. Please see the DSM-5 for additional information.1
The alternative dimensional model of Avoidant Personality Disorder in the DSM-5 identifies the internalization of distress, high levels of negative affectivity, behavioral inhibition and avoidance, and low levels of extraversion as salient diagnostic features for Avoidant Personality Disorder.1
Causes & Triggers of Avoidant Personality Disorder
The causes of Avoidant Personality Disorder are unresolved. Like other personality disorders outside of the Cluster B category, there has been very little empirical research on this disorder. The research has more often focused on Social Anxiety Disorder, perhaps due to its prevalence in the population and higher treatability. There are no specific identified triggering events or time of onset for Avoidant Personality Disorder. Of note, Cluster B personality disorders represent patterns of emotional, dramatic, or unpredictable thinking or behavior.
Most of the literature on Avoidant Personality Disorder states that the interaction of genetically inherited traits and environmental influences are the likely cause. Some research has shown that individuals with Avoidant Personality Disorder are often victims of childhood maltreatment, particularly emotional abuse and neglect.6 However, Dr. Gregory W. Lester points out that research data also show that aversive childhood experiences are not predictive of personality disorders. The majority of abused children (about 68%) recover without symptoms.7
There are several theories implicating the causation of personality disorders in general, they are attachment theory, excessive trait theory, and the Five-Factor Model. Attachment theory states that reliable, secure attachment (ie, comfort, food, warmth, positive regard and love) provided by a caregiver allows a young child to build internal working models that become personality-structure traits. Without secure attachment, a child may build unhealthy views of self and others which increase the likelihood of developing psychopathology.5,6,8
Dr. Lester states that the personality is like a “toolkit” with tools or “traits” that aid in a person’s flexibility and adaptability. Individuals with personality disorders have one trait exclusively, like timidity in Avoidant Personality Disorder.7 They do not have enough other diverse traits to meet changing needs, such as resilience in the case of Avoidant Personality Disorder. Individuals with personality disorders do the same thing over and over again no matter how negative the consequences. They lack the insight to see that it is their own behaviors that cause negative effects.7
The Five-Factor Model (FFM) divides and measures personality structure using five domains: Negative Affectivity; Detachment; Antagonism, Disinhibition, and Psychoticism.1 Within the domains are 25 traits measured on a continuum used to determine the extent of the trait. Avoidant Personality Disorder displays the extreme Negative Affectivity (anxiousness) trait overwhelming all other personality traits. The sum of the five traits indicates the intensity of dysfunction.1
When Is Avoidant Personality Disorder Diagnosed?
Avoidant Personality Disorder is not diagnosed until early adulthood. Children and adolescents who are shy or timid are likely to grow out of these behaviors with time, interpersonal connections, and adequate social experiences. Shyness can be a part of adolescent development and tends to decline with maturity. It is important that this diagnosis is avoided in children.1
Avoidant Personality Disorder can be diagnosed in adults who consistently behave in the following ways:
- Excessively avoid work that includes being around people
- Cannot bear to be criticized because they are afraid they might blush or cry
- Appear “invisible” and are reluctant to speak because they are afraid of being noticed or are afraid of being wrong
- Are isolated without friends or social groups
- Are hypervigilant of the emotions and behavior of others (watching for trouble)
- Unwilling to take risks or try anything new or novel
- Don’t know the social rules, always feeling like an outsider who can’t fit in
- The smallest slight is taken as total rejection and they are extremely hurt by it
- Exaggerate the potential danger of ordinary life situations
- Long to be loved, secure, connected and have a certain future
Treatment of Avoidant Personality Disorder
Treatment for all personality disorders requires firm boundaries. This plan includes a clear written agreement regarding the terms of therapy, including expected length, frequency, the time in sessions, phone calls, payments, what to do in a crisis, appropriate behaviors, explicit treatment targets and the consequences of violating any of these boundaries.7
As presented in the article, “Avoidant Personality Disorder: Current Insights,” Lampe and Malhi point out that “an understanding of attachment difficulties in Avoidant Personality Disorder appears especially relevant to treatment…Targeting self-concept, experiential avoidance, and maladaptive schemas may also be helpful. However, optimal treatment has yet to be empirically established.”6
Therapy
Overall, the therapeutic relationship is most essential. The therapist will often be the positive surrogate attachment figure to counter the “fearful childhood attachment” the client experienced. The therapist must demonstrate commitment to the long-term, and provide validation, empathy and understanding while insisting that the client make changes. Boundaries are imperative due to the closeness of the relationship.
All therapies for personality disorders involve four analytical techniques used in sessions:
- Therapist pointing out the connections between thoughts, feelings and behaviors, “You do this then this happens…” in order to expand the Self
- Making observations on “what the client is not seeing” to increase observing ego
- Identifying where the problem-solving stops and emotional drama begins to increase problem-solving ability
- Pushing for new thoughts, feelings and behaviors, and teaching skills to increase adaptability7
Cognitive Behavior Therapy (CBT)
CBT models demonstrate the influence of events, thoughts, emotions, and body sensations on behaviors. By identifying the negative thoughts associated with negative consequences, the person’s thoughts, emotions and behaviors can be modified or changed to promote new positive outcomes.
CBT therapists guide clients on how to use tools to make these changes. Using homework, the client practices the tools outside the sessions. Clients are encouraged to chart each step of the change process and review it in treatment. During the process, the client gains a deeper level of understanding about early influences that contributed to a negative sense of Self called a schema.
Dialectical Behavior Therapy (DBT)
DBT is a specialized treatment specifically for personality disorders. It relies on building a new concept of the world using dialectics, which refer to the mind’s comprehension of concepts by insight into polar opposites.
DBT therapy targets behaviors that need to change and provides skill building and problem-solving to facilitate new behavior. DBT skills training focuses on Mindfulness, Emotion Regulation, Interpersonal Effectiveness, and Distress Tolerance. Learning these skills along with a new paradigm creates the flexibility and adaptability that improves the lives of individuals with personality disorders.
Interpersonal Reconstructive Therapy (IRT)
IRT focuses on the causes of personality disorder psychopathology. Treatment starts with a detailed case formulation based on early-attachment patterns that affected the individual’s personality.
This case formulation becomes the client’s road map for treatment. During the course of therapy, the client is taken through the following five steps:
- Collaboration
- Learning about Patterns, Where They Are From, and What They Are For
- Blocking Maladaptive Patterns
- Enabling the Will to Change
- Learn New Patterns3
Medication
There are currently no US Food and Drug Administration approved medications for personality disorders, including Avoidant Personality Disorder. Medication therapies consist of medicating symptoms of co-occurring disorders like major depressive disorder.4,6 Depression and anxiety are the two most common features of Avoidant Personality Disorder treated with medication.
The research available on Social Anxiety Disorder is the basis for medication therapy for Avoidant Personality Disorder. Serotonin-specific reuptake inhibitors (SSRIs) and serotonin noradrenaline reuptake inhibitors (SSNIs) antidepressant medications are effective in treating SAD. Because Avoidant Personality Disorder and SAD are closely related disorders with similar symptoms, it is thought that the same medications are effective for treating Avoidant Personality Disorder. Medications for Avoidant Personality Disorder must be managed on a case-by-case basis by a psychiatric practitioner.6
How to Get Help for Avoidant Personality Disorder
Finding a qualified therapist to treat Avoidant Personality Disorder can be somewhat difficult. There are many therapists who take short courses in personality disorder treatment, but that does not ensure they are qualified to treat Avoidant Personality Disorder. It is important to seek professionals with specialized training in and experience with treating personality disorders, because inept treatment is worse than no treatment at all.
Do not be afraid to ask therapists about their education, training, certifications, experience and their personal treatment philosophy. It is important to have the right fit so that treatment goals can be accomplished within a safe, honest, trustworthy environment in as short a time frame as possible. Qualified referrals are available on online directories.
There are several online groups created for individuals with personality disorders, but they are not specific to Avoidant Personality Disorder. The groups can be informative and encouraging. They remind people that they are not alone and not as unusual as they imagine. Try Personality Disorders Awareness Network Resources for a list of online personality disorder groups.
Individuals with Avoidant Personality Disorder are not very effective at group work and find it hard to show up and engage; however, they may be more successful in online groups than in person. In fact, individuals with Avoidant Personality Disorder often have rich fantasy lives and can be excellent online gamers. That platform can provide some positive social interaction and reinforcement for taking a risk.
Avoidant Personality Disorder Statistics
Lampe and Malhi present the most current Avoidant Personality Disorder data. They estimated that the frequency of Avoidant Personality Disorder ranges from 1.5%–2.5%. The authors noted that based on existing research women appear at higher risk for Avoidant Personality Disorder, with little data concerning age of onset.6
In some studies, it was found that individuals with Avoidant Personality Disorder are less likely to be married or living with a partner. Those with Avoidant Personality Disorder often attain less education and are more likely to collect disability.6
Living With Avoidant Personality Disorder
Clients with Avoidant Personality Disorder often report that their shyness in childhood led to ridicule by others, thus resulting in extreme loneliness, little affection, instilled shame, and feelings of isolation. Living in an environment in which they received little positive emotional attachment or social-skill building led them to retreat inwardly.
Some clients recognize that they were shamed into compliance and never felt good enough to belong (either at home or in the outside world). Social avoidance became their basic defense against constant rejection and disappointment. They longed, however, for connection and to be loved.9
If this pattern of social avoidance continues through adolescence when social development is at its peak, it increases the likelihood of lifetime impairment. Constant and unremitting feelings of inadequacy, fear of rejection, and reluctance to take any social risks reinforce isolation for those with Avoidant Personality Disorder. Isolation then ensures lack of social contact and feelings of shame, and the cycle continues.
Taking action to break the cycle can make a remarkable difference. Connecting with one person or an organization that is warm, open, and non-judgmental could be a first step. This could be a church, a knitting circle, meditation group or gaming club. Those affected should advance in increments and not huge steps. Stop and reflect on the positive aspects of the experience and small accomplishments. Keep a journal noting what went right and what needs to be changed. Make a gratitude list of each improvement no matter how small.
Treatment can help. One is not doomed to living in the endless loop of disconnected unhappiness. Taking the first risk of connecting to a therapist who can help starts the road to positive change. With time and problem-focused therapy, behaviors can change and one can develop a satisfying life.
Avoidant Personality Disorder Tests & Quizzes
Be wary of online tests. There is so little research on this disorder that there are no reliable assessments to take on one’s own. Only mental-health practitioners can make accurate diagnoses. Providers use a variety of screens, assessments and evaluations to determine whether a client meets criteria for this disorder.
Here are a few basic screening tests that may be helpful, but be sure to consult with a mental health professional if you think you may have a personality disorder:
For Further Reading
The following are helpful additional resources for anyone impacted by Avoidant Personality Disorder:
