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* This is the Professional Version. *

Avoidant Personality Disorder (AVPD)

By Lois Choi-Kain, MD, Gunderson Residence of McLean Hospital;Harvard Medical School

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Patient Education

Avoidant personality disorder is characterized by the avoidance of social situations or interactions that involve risk of rejection, criticism, or humiliation. Diagnosis is by clinical criteria. Treatment is with psychotherapy, anxiolytics, and antidepressants.

People with avoidant personality disorder have intense feelings of inadequacy and cope maladaptively by avoiding any situations in which they may be evaluated negatively.

Between 1 to 5.2% of the general population are estimated to have avoidant personality disorders; it is more common among women than among men.

Comorbidities are common. Patients often also have major depressive disorder, dysthymia, obsessive-compulsive disorder, or an anxiety disorder (eg, panic disorder, particularly social phobia [social anxiety disorder]). They may also have another personality disorder (eg, dependent, borderline). Patients with social phobia and avoidant personality disorder have more severe symptoms and disability than those with either disorder alone.

Etiology

Research suggests that experiences of rejection and marginalization during childhood and innate traits of social anxiousness and avoidance may contribute to avoidant personality disorder. Avoidance in social situations has been detected as early as about age 2 yr.

Symptoms and Signs

Patients with avoidant personality disorder avoid social interaction, including those at work, because they fear that they will be criticized or rejected or that people will disapprove of them, as in the following situations:

  • They may refuse a promotion because they fear co-workers will criticize them.

  • They may avoid meetings.

  • They avoid making new friends unless they are sure they will be liked.

These patients assume people will be critical and disapproving until rigorous tests proving the contrary are passed. Thus, before joining a group and forming a close relationship, patients with this disorder require repeated assurances of support and uncritical acceptance.

Patients with avoidant personality disorder long for social interaction but fear placing their well-being in the hands of others. Because these patients limit their interactions with people, they tend to be relatively isolated and do not have a social network that could help them when they need it.

These patients are very sensitive to anything slightly critical, disapproving, or mocking because they constantly think about being criticized or rejected by others. They are vigilant for any sign of a negative response to them. Their tense, anxious appearance may elicit mockery or teasing, thus seeming to confirm their self-doubts.

Low self-esteem and a sense of inadequacy inhibit these patients in social situations, especially new ones. Interactions with new people are inhibited because patients think of themselves as socially inept, unappealing, and inferior to others. They tend to be quiet and timid and try to disappear because they tend to think that if they say anything, others will say it is wrong. They are reluctant to talk about themselves lest they be mocked or humiliated. They worry they will blush or cry when they are criticized.

Patients with avoidant personality disorder are very reluctant to take personal risks or participate in new activities for similar reasons. In such cases, they tend to exaggerate the dangers and use minimal symptoms or other problems to explain their avoidance. They may prefer a limited lifestyle because of their need for security and certainty.

Diagnosis

  • Clinical criteria ( Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5])

For a diagnosis of avoidant personality disorder, patients must have a persistent pattern of avoiding social contact, feeling inadequate, and being hypersensitive to criticism and rejection, as shown by ≥ 4 of the following:

  • Avoidance of job-related activities that involve interpersonal contact because they fear that they will be criticized or rejected or that people will disapprove of them

  • Unwillingness to get involved with people unless they are sure of being liked

  • Reserve in close relationships because they fear ridicule or humiliation

  • Preoccupation with being criticized or rejected in social situations

  • Inhibition in new social situations because they feel inadequate

  • A view of self as socially incompetent, unappealing, or inferior to others

  • Reluctance to take personal risks or participate in any new activity because they may be embarrassed

Also, symptoms must have begun by early adulthood.

Differential diagnosis

Avoidant personality disorder must be distinguished from the following 2 disorders:

  • Social phobia: Differences between social phobia and avoidant personality disorder are subtle. Avoidant personality disorder involves more pervasive anxiety and avoidance than social phobia, which is often specific to situations that may result in public embarrassment (eg, public speaking, performing on stage). However, social phobia may involve a broader avoidance pattern and thus may be hard to distinguish. The 2 disorders often occur together.

  • Schizoid personality disorder: Both disorders are characterized by social isolation. However, patients with schizoid personality disorder become isolated because they are disinterested in others, whereas those with avoidant personality disorder become isolated because they are hypersensitive to possible rejection or criticism by others.

Other personality disorders may be similar in some ways to avoidant personality disorder but can be distinguished by characteristic features (eg, by a need to be cared for in dependent personality disorder vs avoidance of rejection and criticism in avoidant personality disorder).

Treatment

  • Cognitive-behavioral therapy focused on social skills

  • Supportive psychotherapy

  • Psychodynamic psychotherapy

  • Anxiolytics and antidepressants

General treatment of avoidant personality disorder is similar to that for all personality disorders.

Patients with avoidant personality disorder often avoid treatment.

Effective therapies for patients with both social phobia and avoidant personality disorder include

  • Cognitive-behavioral therapy that focuses on acquisition of social skills, done in groups

  • Other group therapies if the group consists of people with the same difficulties

Patients with avoidant personality disorder benefit from

  • Individual therapies that are supportive and sensitive to the patient's hypersensitivities toward others

Psychodynamic psychotherapy, which focuses on underlying conflicts, may be helpful.

Effective drug therapy includes monoamine oxidase inhibitors (MAOIs), SSRIs, and anxiolytics, which help reduce anxiety enough to enable patients to expose themselves to new social situations.

* This is the Professional Version. *