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Avoidant Personality Disorder (AVPD)

By

Mark Zimmerman

, MD, Rhode Island Hospital

Last full review/revision May 2021| Content last modified May 2021
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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.

Reported prevalence of avoidant personality disorder in the US varies, but estimated prevalence is about 2.4%. Avoidant personality disorder affects women and men equally.

Comorbidities are common. Patients often also have major depressive disorder Major depression (unipolar disorder) Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown... read more , persistent depressive disorder, obsessive-compulsive disorder Obsessive-Compulsive Disorder (OCD) Obsessive-compulsive disorder (OCD) is characterized by recurrent, persistent, unwanted, and intrusive thoughts, urges, or images (obsessions) and/or by repetitive behaviors or mental acts that... read more , or an anxiety disorder Overview of Anxiety Disorders Everyone periodically experiences fear and anxiety. Fear is an emotional, physical, and behavioral response to an immediately recognizable external threat (eg, an intruder, a car spinning on... read more (eg, panic disorder Panic Attacks and Panic Disorder A panic attack is the sudden onset of a discrete, brief period of intense discomfort, anxiety, or fear accompanied by somatic and/or cognitive symptoms. Panic disorder is occurrence of repeated... read more , particularly social phobia Social Phobia Social phobia is fear of and anxiety about being exposed to certain social or performance situations. These situations are avoided or endured with substantial anxiety. Phobias are a type of... read more [social anxiety disorder]). They may also have another personality disorder (eg, dependent Dependent Personality Disorder (DPD) Dependent personality disorder is characterized by a pervasive, excessive need to be taken care of, leading to submissiveness and clinging behaviors. Diagnosis is by clinical criteria. Treatment... read more , borderline Borderline Personality Disorder (BPD) Borderline personality disorder is characterized by a pervasive pattern of instability and hypersensitivity in interpersonal relationships, instability in self-image, extreme mood fluctuations... read more ). Patients with social phobia and avoidant personality disorder have more severe symptoms and disability than those with either disorder alone.

Etiology of AVPD

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 years.

Symptoms and Signs of AVPD

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 coworkers 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 of AVPD

  • 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

This pattern is shown by the presence of 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

  • Self-assessment 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:

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 Dependent Personality Disorder (DPD) Dependent personality disorder is characterized by a pervasive, excessive need to be taken care of, leading to submissiveness and clinging behaviors. Diagnosis is by clinical criteria. Treatment... read more vs avoidance of rejection and criticism in avoidant personality disorder).

Treatment of AVPD

  • Cognitive-behavioral therapy focused on social skills

  • Supportive psychotherapy

  • Psychodynamic psychotherapy

  • Anxiolytics and antidepressants

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.

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