What Is Personality?
Personality is a particular set of behaviors, traits, emotions, and patterns that make up a person, his character, and their individuality. Personality includes how we see the world, our thoughts, attitudes, and feelings. Personality is strongly influenced by our values, attitudes, perception of ourselves, and predicts our reactions to people, the world, stress, and problems.
While there are many different definitions of personality, most focus on the pattern of behaviors and characteristics that can help predict and explain a person’s behavior.
What Is A Personality Disorder?
A person’s personality may be influenced by experiences, environment (surroundings, life situations) and inherited – genetic – characteristics. A person’s personality typically stays the same over time.
While personality disorders differ from mental disorders, like schizophrenia and bipolar disorder, they do, by definition, lead to significant impairment. Personality disorders are estimated to affect about 10 percent of people, although this figure ultimately depends on where clinicians draw the line between a “normal” personality and one that leads to significant impairment.
A personality disorder is a way of thinking, feeling, and behaving that is different from the expectations of the culture, causes distress, problems functioning, and lasts over time. Personality disorders are almost always associated with marked social and personal disruption and are both pervasive and inflexible. While these behaviors can produce poor coping skills, leading to personal issues including anger, anxiety, depression, and distress, they are considered appropriate by the person with the disorder.
There are 10 specific types of personality disorders. Personality disorders are long-term patterns of behavior and inner experiences that differs significantly from what is expected. The pattern of experience and behavior begins by late adolescence or early adulthood and causes distress or problems in functioning.
Without treatment, personality disorders can be long-lasting. Personality disorders must affect at least two of the following areas:
- Way of thinking about oneself and others
- Way of responding emotionally
- Way of relating to other people
- Way of controlling one’s behavior
What Is Avoidant Personality Disorder?
No one enjoys criticism, rejection, or embarrassment, but sometimes certain people spend their entire life avoiding these situations altogether, by in part, avoiding situations that could produce such situations. They may avoid confrontations, not take credit for work that is theirs, distance themselves from others, and try to avoid any interactions with other people. Sometimes, these socially-challenged people who have a over-the-top reaction to rejection while feeling consistent feelings of inadequacy are diagnosed with a personality disorder, a mental illness known as avoidant personality disorder (AVPD).
Avoidant personality disorder is one of a group of mental illnesses called personality disorders, which are characterized by feelings of nervousness and fear. People with avoidant personality disorder have poor self-esteem and feel very down about themselves and the ways in which they relate to others. Often. people who have AvPD have an intense fear of rejection and being negatively judged by others. These feelings make them very uncomfortable in social situations, leading them to avoid group activities and contact with others.
AVPD (also called Anxious Personality Disorder or Anxious (Avoidant) Personality Disorder) is a personality disorder that is characterized by a pattern of withdrawal, self-loathing and an extremely heightened sensitivity to criticism. People who have AVPD usually consider themselves socially unsuccessful and socially awkward tend to remove themselves from social situations (whenever possible) in the hopes of avoiding the feeling – or risk – of feeling rejected by others. They spend a lot of time focusing on their shortcomings and are very hesitant to form relationships in which rejection is possible, which naturally often results in feelings of loneliness, becoming disengaged from relationships at work, and having few people they truly feel safe with. People with AVPD might also refuse a promotion, make excuses to miss meetings, or be too fearful to engage in events where they might make friends.
Those who live in a relationship with a person who suffers from avoidant personality disorder often recognize that something is not quite right with the behavior of their family member or loved-one but often don’t have any idea what the “not quite right” bit is. Partners and loved ones of those who have AvPD may feel trapped in the relationship and frustrated by their loved-one’s tendency to pull them away from family, friends, and other “everyday” social settings.
People who are in a relationship with a person who suffers from AVPD may also experience pressure to isolate themselves along with them or pressure to protect them from criticism or to create an artificial or dysfunctional “bubble” or ideal environment around them in which they can escape the risk of negative self-thought.
Avoidant personality disorder (AvPD) is a Cluster C personality disorder; cluster C personality disorders are those in which the affected exhibit a notable pattern of severe social anxiety, social inhibition, feelings of inadequacy and inferiority, extreme sensitivity to negative evaluation and rejection, as well as avoidance of social interaction despite a strong desire for intimacy. The behavior is usually noticed by early adulthood and occurs in most situations.
People with AvPD often consider themselves to be socially inept, personally unappealing, and avoid social interaction for fear of being ridiculed, humiliated, rejected, or disliked. They generally avoid becoming involved with others unless they are certain they will be liked. As the name suggests, the main coping mechanism of those with AvPD is avoidance of feared situations. Childhood emotional neglect (in particular, the rejection of a child by one or both parents) and peer group rejection are associated with an increased risk for its development; however, it is possible for AvPD to occur without any notable history of abuse or neglect.
Is Avoidant Personality Disorder The Same As Social Anxiety?
There remains much controversy over the notion that social anxiety disorder is simply an advanced form of AvPD. Researchers and clinicians used to believe that avoidant personality disorder only occurred in conjunction with social anxiety disorder (SAD). However, more recent research has shown that there is a significant percentage of people with AVPD who do not meet the criteria for social anxiety disorder.
Let’s examine this further:
Social anxiety disorder (SAD) is, naturally, very distressing for those who must cope with it in their daily lives. Typically, people with SAD understand that their fears of rejection and criticism are out of proportion with reality, though these reactive thought patterns persist. They may give a lot of energy to imagining worst-case scenarios but do not venture out of the house to face these possibilities. These habits make forming and maintaining friendships and relationships extremely challenging, and people with advanced social anxiety disorder may live very isolated lives. The resulting stress of SAD may also cause nervous physical symptoms, such as sweating, dizziness, trembling, difficulty breathing, upset stomach, increased heart rate, and tension within the body.
The overwhelming symptoms of social anxiety can contribute to the trauma of social situations in the end, generating more fear and anxiety in the future.
Symptoms of avoidant personality do disorder mirror those of social anxiety disorder but reach further into a person’s understanding of their own identity and their dysfunction in everyday life.
People with avoidant personality disorder:
- Have extremely low self-esteem because they believe that they are inferior, incompetent, and entirely deserving of the rejections they anticipate from others.
- Are incredibly sensitive to criticism – real or imagined – to such point that it is so crippling that they have very few, or even no, social interactions on a regular basis.
- May not be able to succeed in a job because of the socialization it requires and opt for jobs in which they can work at home
- Are often without friendships and romantic relationships, if they want these connections in their lives. Looking for real connections with people raises the stakes, and people with avoidant personality disorder may feel extreme anxiety about interacting with these people.
Those with social anxiety disorder may have low self-esteem in social situations but do not actually believe they are inferior or worthy of the outside judgments they fear, while those with avoidant personality disorder internalize this criticism so completely that they believe the pending hostile perspective is justified. Their perception is distorted so much so that they do not even see themselves as they are in reality—let alone how the world and the people around them really are. It is as if avoiding others and social situations is a way of avoiding themselves, however. they continue to live with these fears and distress, withdrawing further and becoming severely isolated. They may develop overwhelming anxiety in anticipation of going to the grocery store, simply walking out to the mailbox, or having an unexpected visitor show up at the door.
Sometimes it may be difficult to distinguish whether a person has social anxiety disorder or avoidant personality disorder, or both conditions. Typically, a person with AVPD will experience anxiety and avoidance in all arenas of life, whereas a person with social anxiety may only have fears specific to certain situations, such as public speaking or performing.
What is a Cluster C Personality Disorder?
Different personality disorder diagnoses are organized by cluster,” and those who have Cluster C personality disorders experience characteristics and feelings that involve being particularly anxious or fearful. Avoidant personality disorder is a Cluster C personality disorder, as are dependent personality disorder, and obsessive-compulsive personality disorder.
How Common Is Avoidant Personality Disorder?
It is estimated that about 2.5 percent of the population has avoidant personality disorder and seems to affect men and women equally. It generally begins in infancy and childhood and continues into adulthood. As with most personality disorders, avoidant personality disorder usually is not diagnosed in people younger than 18 years of age.
New information has found that in several separate clinical studies, Avoidant Personality Disorder may actually affect anywhere from 1.8% to 5.2% of the general population. Remember this, people who are diagnosed with Avoidant Personality Disorder also frequently meet the criteria for other personality disorders.
This table below shows how statistically likely it is that a person who is diagnosed with AVPD will also meet the criteria for another personality disorder. The more positive the number, the more likely it is that a person will be diagnosed with the second personality disorder listed. The more negative the number, the less likely it is that a person will be diagnosed with the second personality disorder in the table.
|Personality Disorder||Co-Morbidity Odds Ratio|
|Dependent Personality Disorder||.70|
|Paranoid Personality Disorder||0.70|
|Obsessive-Compulsive Personality Disorder||0.63|
|Schizoid Personality Disorder||0.55|
|Borderline Personality Disorder||0.54|
|Schizotypal Personality Disorder||0.53|
|Antisocial Personality Disorder||0.05|
What Causes Avoidant Personality Disorder?
Researchers don’t completely understand what causes avoidance personality disorder, but they believe it is a combination of genetics and environmental factors, meaning that as of this writing, no single cause is to blame for the development of Avoidant Personality Disorder. The following factors may greatly influence the development of AvPD, but there’s no accepted single root cause for the disorder.
Early Childhood Experiences:
Millon and others considered early interactions with parents as an important etiological factor in AVPD. The likely importance of early caregiver experiences is underscored by adoption studies. Increased odds of PD in adoptees were evident in the National Epidemiological Survey on Alcohol and Related Conditions (NESARC) study, but the odds were highest, about double that of non-adoptees, for paranoid, antisocial, and avoidant PDs.
Early childhood experiences may be linked to the development of AVPD. Research suggests that children who see their caregivers as lacking in affection and encouragement and/or experience rejection from them may be at increased risk. So are children who experience abuse, neglect, and an overall lower level of care. In response to these experiences, children may avoid socializing with others as a coping strategy.
Some studies suggest that patients with AvPD are more likely to see their parents as less affectionate, more rejecting, guilt-engendering, and less encouraging of achievement than matched controls. AvPD has been linked to a recalled history of neglect, abuse, overprotection, and lower care. The CLPS found relatively few differences between AvPD and other PDs on experiences of physical or emotional abuse, or caretaker emotional denial. However, there are some noteworthy differences: those with a primary diagnosis of AvPD reported fewer positive relationships with other adults, poorer parental social ability, less sexual abuse, and physical neglect than a group of persons with other PDs. Research has also discovered associations mediated in part by a maladaptive schema of belief in the need to subjugate personal needs, wants, and desires to avoid negative interpersonal outcomes, although overall few relationships with early maladaptive schemas were evident.
In summary, despite some variability of findings, there seems to be reasonable support for an association between neglect and emotional abuse, and perhaps less encouragement by early caregivers and later AvPD symptomatology. Recall bias influenced by underlying hypersensitivity cannot be excluded as a contributor to these findings, but twin studies point to some role for environmental factors, and negative experiences within the family would appear a likely candidate.
Attachment provides an explanatory model for the link between temperament, adverse childhood environment, and personality disorders. An attachment style referred to as avoidant, detached, or dismissing (also referred to as an “anxious/avoidant” style) has been proposed to contribute to the development of AvPD. This attachment style may be associated with a negative self-concept and a fear of intimate relationships. A fearful attachment style – involving a desire for intimacy in the presence of interpersonal distrust and fear of rejection – is now thought to be of major relevance to people who have AvPD. Indeed, Bartholomew regarded the fearful style, when extreme, as typical of AVPD.
A number of studies have confirmed the theorized relationship between AvPD and both anxious and avoidant strategies. Using the four-category model of Bartholomew and Horowitz, which posits that attachment is classified into one of four groups determined by positive or negative views of the self and positive or negative views of others, some studies also identified a fearful attachment style in AVPD. In the four-category model, the fearful attachment style may be the most disabling, since it is associated with negative views of both self and other. Research suggests that experiences with critical, demeaning, and neglectful early caregivers may increase the risk of developing a fearful attachment style.
These findings are important because attachment style is highly relevant to assessment and treatment; It is more difficult for a therapist to establish and maintain a relationship with a person who is distrustful of others, is hypersensitive to criticism and rejection, and relies on avoidant coping strategies.
Links between early childhood experiences and core features of AVPD: hypervigilance, avoidance, low self-esteem, and negative self-concept:
It’s been postulated that a child may develop hypervigilance as a coping strategy when a parent is inaccessible or inconsistent and this hypervigilance may then move to other social situations. This might be expected to apply equally to social anxiety disorder. Others suggest that repeated negative experiences with parents might lead the child to expect unpleasant or distressing interactions, and to then employ avoidance as a coping strategy. Over time, this might become the default strategy. The resulting social isolation then predisposes these people to feel greater emotional distress. Millon viewed parental rejection or denigration as a critical factor in the loss of self-esteem in the child.
A role for temperamental factors has also been proposed with some supportive evidence:
- Personality rigidity
- Major harm avoidance
- Low novelty-seeking
- Overactive behavioral inhibition system
It also seems likely that social anxiety disorder and AVPD share some temperamental vulnerability factors:
- Negative emotionality (neuroticism)
- Behavioral inhibition
Temperamental factors may increase the person’s vulnerability to the effects – and possibly even the risk – of negative childhood experiences. They may also influence the selection of coping strategies, such as avoidance, and the adverse impact of maladaptive strategies. A relationship between attachment and temperament has also been described. For example, the amount and expression of distress an infant experiences upon separation from the early caregiver may be influenced by temperamental traits, and the responsiveness of the caregiver may influence attachment.
Genetic studies have the potential to offer insight into the relative contributions of genes and environment, as well as more specifically to inform the question of diagnostic validity. A heritability coefficient for AVPD of 0.64 has been estimated in one study. Initial and 10-year follow-up genetic findings in people who had avoidant personality disorder and social anxiety disorder using data from the Norwegian Twin Registry indicated that genetic influences on AVPD were stable over time, but the genetic risk for SAD was more variable.
The authors concluded that environmental factors contributed to co-occurrence of AVPD and SAD, and that there are potentially distinct factors underlying SAD and AVPD.
In summary, these studies suggest a complex relationship between genes, temperament, early childhood environment, attachment style, and personality in AVPD, which remains to be fully elucidated. The research indicates some shared vulnerability with SAD, but also some points of difference.
What Are Some Of The Characteristics of Avoidant Personality Disorder?
The following is a list of some of the more common characteristics and traits of people who suffer from Avoidant Personality Disorder (AVPD) from Out of The Fog:
These traits are listed as a guideline only and are not intended for actual or diagnosis or as diagnostic criteria. People who suffer from avoidant personality disorder are each unique and so each person will display a different subset of traits. It’s also important to remember that everyone displays “avoidant” behaviors from time to time. Therefore, if a person exhibits one or some of these traits, that does not necessarily qualify them for a diagnosis of AVPD.
Always/Never Statements are declarations containing the words “always” or “never” especially used in arguing in interpersonal relationships, while often used, these statements are usually not true They are commonly used but rarely true.
Avoidance – Purposefully withdrawing from relationships with others as a preemptive defensive measure to help reduce the risk of rejection, accountability, criticism, or exposure.
Blaming – Rather than identifying ways of dealing with a problem together, these people blame other people who “created the problem.”
Catastrophizing – Automatically assuming a “worst case scenario” in absolutely every situation, thus wrongly characterizing minor or moderate problems or issues as catastrophic events.
Circular Conversations – People who engage in circular conversations (generally within the context of an argument) can go on almost endlessly, repeating the same patterns, never coming to an actual conclusion together.
Confirmation Bias – The tendency involves paying much more attention to things that reinforce their already-held beliefs rather than things which contradict them.
“Control-Me” Syndrome – Some people have the tendency to engage in relationships with people who have a controlling narcissistic, antisocial, or “acting-out” nature.
Cruelty to Animals – acts of violence toward helpless animals have been discovered to statistically occur more frequently in those who have a personality disorder rather than the general population more often in people who suffer from personality disorders than in the general population.
Denial – the imagination or belief that some awful, traumatic situation didn’t exist and that they have no memory of the event.
Dependency – far out of normal and appropriate constant reliance by an adult to another adult, allowing the other adult to make decisions about illness, health, and personal and emotional well-being
Depression – Many individuals who have been diagnosed are also diagnosed with depression and depression symptoms
Escape To Fantasy – Instead of dealing with the present crisis or the here and now, a person escapes to a fantasy world
Identity Disturbance – a distorted and/or inconsistent view of themselves
Imposed Isolation – occurs when abuse leads a person becoming isolated from their support network, including friends and family.
Lack of Object Constancy – An inability to remember that people or objects are consistent, trustworthy and reliable, especially when they are out of your immediate field of vision.
Low Self-Esteem – negatively distorted view of self that is disingenuous to reality
Magical Thinking – Looking for supernatural connections between external events and one’s own thoughts, words and actions.
Manipulation – The practice of steering an individual into a desired behavior for the purpose of achieving a hidden personal goal.
Masking – Covering up one’s own natural outward appearance, mannerisms and speech in dramatic and inconsistent ways depending on the situation.
Neglect – A passive form of abuse in which the physical or emotional needs of a dependent are disregarded or ignored by the person responsible for them.
Objectification – The practice of treating a person or a group of people like an object.
Obsessive-Compulsive Behavior – An inflexible adherence to arbitrary rules and systems, or an illogical adherence to cleanliness and orderly structure.
Panic Attacks – Short intense episodes of fear or anxiety, often accompanied by physical symptoms, such as hyperventilating, shaking, sweating and chills.
Parentification – A form of role reversal, in which a child is inappropriately given the role of meeting the emotional or physical needs of the parent or of the family’s other children.
Passive-Aggressive Behavior – Expressing negative feelings in an unassertive, passive way.
Perfectionism – The maladaptive practice of holding oneself or others to an unrealistic, unattainable or unsustainable standard of organization, order, or accomplishment in one particular area of living, while sometimes neglecting common standards of organization, order or accomplishment in other areas of living.
Sabotage – The spontaneous disruption of calm or status quo in order to serve a personal interest, provoke a conflict or draw attention.
Selective Competence – Demonstrating different levels of intelligence, memory, resourcefulness, strength or competence depending on the situation or environment.
Self-Loathing – An extreme hatred of one’s own self, actions or one’s ethnic or demographic background.
Self-Victimization – Casting oneself in the role of a victim.
Splitting – The practice of regarding people and situations as either completely “good” or completely “bad”.
Testing – Repeatedly forcing another individual to demonstrate or prove their love or commitment to a relationship.
Thought Policing – Any process of trying to question, control, or unduly influence another person’s thoughts or feelings.
Tunnel Vision – The habit or tendency to only see or focus on a single priority while neglecting or ignoring other important priorities.
What Are The Symptoms of Avoidant Personality Disorder?
While avoidant personality disorder symptoms include anxiety during social contexts, they also differ sharply from social anxiety in the underlying beliefs and sense of self that drive their anxiety. Fear of social interaction arises from a deeply held sense of insecurity, inferiority, and ineptness. In contrast, many people with social anxiety disorder have healthy self-esteem and do not believe themselves to be inferior to others; social anxiety is not rooted in a particular self-image.
The symptoms of avoidant personality disorder are a highly specific set of beliefs that drive disordered behavior.
To receive a diagnosis, a person must have experienced these components by the time they reach earl adulthood. They also must experience at least four of the following AVPD symptoms, these include:
- Extremely low self-esteem
- Avoidance of activities at work that involve interpersonal contact due to fear of criticism or rejection
- Believing oneself to be inferior, inept, or unappealing to others
- Unwillingness to interact with others unless certain they will receive a positive response
- Highly sensitive to criticism or perceived rejection
- Feeling inadequate and being inhibited in new social situations
- Reluctance to enter social situations or form relationships
- An absence of friendships
- Hesitancy in intimate relationships due to fear of shame
- Preoccupation with criticism in social situations
- Extreme shyness that arises out of fear of doing something wrong
- Unwillingness to try new things for fear of humiliation or embarrassment
Living with avoidant personality disorder can be extremely limiting, as fear and rumination over perceived shortcomings can make even the most simple activities into (possible) emotional minefields.
It is also important to remember that people with this condition do not lack a desire for social contact; in fact, most people with AvPD deeply want to form close relationships and be able to engage in social interactions, but are so restrained by their disruptive thoughts and distorted self-image that they are unable to participate in such activities. If they do have social relationships, they are likely with people considered to be “low-risk” in terms of rejection, humiliation, or judgment, severely restricting social options.
For people with this disorder, the fear of rejection is so strong that they choose isolation rather than risk being rejected in a relationship. The pattern of behavior in people with this disorder can vary from mild to extreme. In addition to their fear of humiliation and rejection, other traits of people with this disorder include the following:
- They are oversensitive and easily hurt by criticism or disapproval.
- They have few, if any, close friends and are reluctant to become involved with others unless certain of being liked.
- They experience extreme anxiety (nervousness) and fear in social settings and in relationships, leading them to avoid activities or jobs that involve being with others.
- They tend to be shy, awkward, and self-conscious in social situations due to a fear of doing something wrong or being embarrassed.
- They tend to exaggerate potential problems.
- They seldom try anything new or take chances.
A diagnosis will require a psychological evaluation by a mental health professional. This evaluation will also rule out other potential diagnoses or determine whether a person has more than one diagnosis.
Psychologist Theodore Millon notes that because most patients present a mixed picture of symptoms, their personality disorder tends to be a blend of a major personality disorder type with one or more secondary personality disorder types. He identified four adult subtypes of avoidant personality disorder:
AvPD Subtype and Description Notable Personality Traits
Phobic avoidant (including dependent features) General apprehensiveness displaced with avoidable tangible precipitant; qualms and disquietude symbolized by repugnant and specific dreadful object or circumstances.
Self-deserting avoidant (including depressive features) Blocks or fragments self awareness; discards painful images and memories; casts away untenable thoughts and impulses; ultimately jettisons self-harm and suicide.
Hypersensitive avoidant (including paranoid features) Intensely wary and suspicious; alternately panicky, terrified, edgy, and timorous, then thin-skinned, high-strung, petulant, and prickly.
Conflicted avoidant (including negativistic features) Internal discord and dissension; fears dependence; unsettled; unreconciled within self; hesitating, confused, tormented, paroxysmic, embittered; unresolvable angst.
Lynn E. Alden and Martha J. Capreol, in 1993, proposed two other subtypes of avoidant personality disorder:
Exploitable-Avoidant Characterised by an inability to express anger towards others or to resist coercion from others. May be at risk for abuse by others.
Cold-Avoidant Characterised by an inability to experience and express positive emotion towards others.
How Are General Personality Disorders Diagnosed?
Before a diagnosis of a personality disorder can be made, they must first meet the criteria for a personality disorder.
The two relevant major systems of classification for personality disorders must be met before any type of specific diagnosis (such as Avoidant PD) can be made.
- International Classification of Diseases (11th revision, ICD-11) published by the World Health Organization
- The Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition, DSM-5) by the American Psychiatric Association.
Both have deliberately merged their diagnoses to some extent, however some differences remain. There are accepted diagnostic issues and controversies with regard to distinguishing particular personality disorder categories from each other. Before a specific diagnosis is made, the general criteria put forth by the ICD-11 and DSM-V must be met.
General Criteria For Diagnosing Personal Disorders:
Both diagnostic systems provide a definition and six criteria for a general personality disorder. These criteria should be met by all personality disorder cases before a more specific diagnosis can be made.
The ICD-10 lists these general guideline criteria:
- Markedly disharmonious attitudes and behavior, generally involving several areas of functioning; e.g. affectivity, arousal, impulse control, ways of perceiving and thinking, and style of relating to others;
- The abnormal behavior pattern is enduring, of long standing, and not limited to episodes of mental illness;
- The abnormal behavior pattern is pervasive and clearly maladaptive to a broad range of personal and social situations;
- The above manifestations always appear during childhood or adolescence and continue into adulthood;
- The disorder leads to considerable personal distress but this may only become apparent late in its course;
- The disorder is usually, but not invariably, associated with significant problems in occupational and social performance.
The ICD adds: “For different cultures it may be necessary to develop specific sets of criteria with regard to social norms, rules and obligations.”
Chapter V in the ICD-10 contains the mental and behavioral disorders and includes categories of personality disorder and enduring personality changes which are defined as, “ingrained patterns indicated by inflexible and disabling responses that significantly differ from how the average person in the culture perceives, thinks, and feels, particularly in relating to others.”
The specific personality disorders in the ICD-11: paranoid, schizoid, dissocial, emotionally unstable (borderline type and impulsive type), histrionic, anankastic, anxious (avoidant) and dependent. In addition, there are the following personality disorders:
- Other specific personality disorders (involves PD characterized as eccentric, haltlose, immature, narcissistic, passive–aggressive, or psychoneurotic.)
- Personality disorder, unspecified (includes “character neurosis” and “pathological personality”).
- Mixed and other personality disorders (defined as conditions that are often troublesome but do not demonstrate the specific pattern of symptoms in the named disorders).
- Enduring personality changes, not attributable to brain damage and disease (this is for conditions that seem to arise in adults without a diagnosis of personality disorder, following catastrophic or prolonged stress or other psychiatric illness).
In the proposed revision of ICD-11, all discrete personality disorder diagnoses will be removed and replaced by the single diagnosis “personality disorder.” Instead, there will be specifiers called “prominent personality traits” and the possibility to classify degrees of severity ranging from “mild”, “moderate”, and “severe” based on the dysfunction in interpersonal relationships and everyday life of the patient.[
In DSM-5, any personality disorder diagnosis must meet the following criteria:
- An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:
- Cognition (i.e., ways of perceiving and interpreting self, other people, and events).
- Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response).
- Interpersonal functioning.
- Impulse control.
- The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
- The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
- The enduring pattern is not better explained as a manifestation or consequence of another mental disorder.
- The enduring pattern is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., head trauma).
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) stresses a personality disorder is an enduring and inflexible pattern of long duration that leads to significant distress or impairment and is not due to use of substances or another medical condition. The DSM-5 lists personality disorders in the same way as other mental disorders:
DSM-5 lists ten specific personality disorders: paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent and obsessive-compulsive personality disorder.
The DSM-5 also contains three diagnoses for personality patterns not matching these ten disorders, but nevertheless exhibit characteristics of a personality disorder:
- Personality change due to another medical condition – personality disturbance due to the direct effects of a medical condition.
- Other specified personality disorder – general criteria for a personality disorder are met but fails to meet the criteria for a specific disorder, with the reason given.
- Unspecified personality disorder – general criteria for a personality disorder are met but the personality disorder is not included in the DSM-5 classification.
World Health Organization (WHO) Criteria:
If symptoms are present, the doctor will begin an evaluation by performing a complete medical history and physical examination. Although there are no laboratory tests to specifically diagnose personality disorders, the doctor might use various diagnostic tests to rule out physical illness as the cause of the symptoms.
The World Health Organization’s ICD-10 lists avoidant personality disorder as anxious (avoidant) personality disorder. It is a requirement of ICD-10 that all personality disorder diagnoses also satisfy a set of general personality disorder criteria.
AvPD is characterized by at least four of the following symptoms according to the ICD-10:
- Persistent and pervasive feelings of tension and apprehension
- Belief that one is socially inept, personally unappealing, or inferior to others
- Excessive preoccupation with being criticized or rejected in social situations
- Unwillingness to become involved with people unless certain of being liked
- Restrictions in lifestyle because of need to have physical security
- Avoidance of social or occupational activities that involve significant interpersonal contact because of fear of criticism, disapproval, or rejection.
Associated features may include hypersensitivity to rejection and criticism.
The DSM-V criteria for diagnosis of AvPD:
The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) also has an Avoidant Personality Disorder diagnosis that refers to a widespread pattern of inhibition around people, feeling inadequate, and being extremely sensitive to negative evaluation. Symptoms begin by early adulthood and occur in a range of situations. Four of seven specific symptoms should be present, which are the following:
- Avoids occupational activities that involve significant 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 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 risk or to engage in any new activities because they may prove embarrassing
Avoidant personality disorder must be distinguished from the following 2 disorders:
Social phobia: Differences between social phobia and avoidant personality disorder are hard to spot. 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).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).
How Is Avoidant Personality Disorder Treated?
Avoidant personality disorder is a chronic, lifelong condition that will continue to disrupt emotions, thoughts, and behaviors unless treatment is sought. Today, there is a wide variety of interventions that can be used to both alleviate acute symptoms and break through the disordered beliefs that underlie those symptoms. These include psychopharmacological and psychotherapeutic treatment options. Of particular note is cognitive behavioral therapy, which aims to replace damaging patterns of thought and behavior with healthier, reality-based alternatives as well as desensitize patients to those situations that act as triggers for symptoms. Additionally, trauma-focused therapies may help you explore the roots of your disorder and create strategies for processing the pain of traumatic childhood experiences while giving you a framework for creating secure attachments. Due to the intensity of the disorder and its profound impact on functionality, long-term residential treatment is often the best treatment milieu, offering the ability to participate in a broad range of therapies to overcome distress.
Treating personality disorders is difficult, because people with these disorders have deep-rooted patterns of thinking and behavior that have existed for many years. However, people with avoidant personality disorder tend to be good candidates for treatment because their disorder causes them significant distress, and most feel the need to develop relationships with other people and reduce the amount of distress they experience at public or at work. This desire can be a motivating factor for people with avoidant personality disorder to follow their treatment plans.
Symptoms will generally decrease in intensity with age, with the peak level of symptoms displayed in their 40s or 50s. Many people with Avoidant Personality Disorder do not seek out treatment, thinking that they are not good enough or that their symptoms don’t matter, even though the disorder has a significant impact upon their lives. Typically help is sought when life becomes too stressful and they are unable to cope with it.
It is extremely important to understand that treating any personality disorder can be difficult, as many of the symptoms have been experienced for many years. Treatment of avoidant personality disorder can employ various techniques, such as social skills training, psychotherapy, cognitive therapy, and exposure treatment to gradually increase social contacts, group therapy for practicing social skills, and sometimes drug therapy.
Significant improvement in the symptoms of personality disorders is possible, with the help of treatment and individual effort.
However, if you are living with avoidant personality disorder, the condition itself can present unique barriers to treatment. Many people with this condition are highly reluctant to enter into mental health treatment due to the social contact inherent to such care. As such, finding the right treatment environment that will encourage participation and foster feelings of safety is paramount. A key issue in treatment is gaining and keeping the patient’s trust, as people who have avoidant personality disorder may start avoiding treatment sessions if they distrust the therapist or fear rejection. Those with Avoidant Personality Disorder often have low self-esteem about any social interactions, often finding it difficult to see the positive in life. This may be challenging for a therapist, as the person may under-report symptoms, deeming them unimportant. A more thorough, detailed interview may be required.
Being a personality disorder, which are chronic and long-lasting mental conditions, avoidant personality disorder is not expected to improve with time without treatment. Being that it is a poorly studied personality disorder and in light of prevalence rates, societal costs, and the current state of research, AvPD qualifies as a neglected disorder.
The following features may help to make treatment less intimidating and more productive:
- Experienced and compassionate clinicians: It is critical that the treatment you choose is staffed by clinicians who have the experience and compassion necessary to effectively address avoidant personality disorder symptomatology. This includes a deep understanding of individual challenges and how to form strong therapeutic alliance. These will allow you to feel safe and comfortable throughout the treatment process.
- Medications should only be prescribed for specific diagnoses occurring co-morbidly (other mental illnesses) that someone with Avoidant Personality Disorder may have.
- Appropriate therapies: While CBT is often particularly helpful for people struggling with avoidant personality disorder, many are initially reluctant to participate in verbally-based therapies that require direct social interactions. As such, the availability of non-verbal therapies, such as holistic, creative, and experiential modalities, can help you feel more comfortable in exploring yourself. These therapies can help bolster your confidence and give voice to your struggles in a supportive and nonjudgmental environment, enhancing your ability to participate in verbal therapies as time goes on.
- Gradual independence: Healing from avoidant personality disorder doesn’t happen overnight and overcoming the functional limitations caused by the disorder can take time. Providing you with the support you need at each stage of healing will be crucial to ensuring that you are met where you are at and are not overwhelmed by responsibilities for which you are not ready. This includes support not only with emotional wellbeing, but with concrete skill-building to increase independence, resilience, and self-reliance. For people with avoidant personality disorder, breaking through isolation, building and maintaining social relationships, and fostering the ability to fulfill educational and professional goals will be of particular importance.
- Psychotherapy Psychotherapy, or talk therapy, is the primary avoidant personality disorder treatment and may include cognitive-behavioral therapy, which focuses on reducing negative thought patterns and building social skills. Sometimes group therapy is used to help people with similar challenges and create a safe space to build solid relationships. Family therapy can also prove useful so that family members understand the condition and can provide a supportive environment that promotes growth and healthy risk-taking.Therapy is generally short-term and oriented toward solution-based approaches looking for solutions to specific life problems. the primary purpose of both individual therapy and social skills.
- Therapy in a safe and encouraging environment can help you explore the intense anxiety you experience in social situations and your fear of rejection or criticism. Together, you and your therapist can practice challenging negative beliefs and explore the small but significant steps you can take to build solid friendships, be more engaged at work, and develop intimate relationships with others.
- Group Therapy Group therapy may be useful if the person with Avoidant Personality Disorder agrees to attend sessions, although group therapy is often a tool that is used later in treatment, once the person feels more comfortable in social situations. Group therapy is designed for people with avoidant personality disorder to start challenging their exaggerated negative beliefs about themselves.
With appropriate care delivered in an environment of love, you can come to uncover your own strengths and purpose and harness your inner resources for healing. The guidance of clinicians will be paramount to this process, but so too will the support of your peers, who can help you learn and practice new social skills and reframe your understanding of yourself as a competent social actor. Most importantly, you will be empowered to develop a strong sense of self-worth, helping you remove the current of self-devaluation that underlies avoidant personality disorder, releasing you from fear and opening up infinite possibilities for your future.
Without treatment, a person with this disorder can become isolated from society, causing long-term
For Loved Ones: Coping Strategies for Avoidant Personality Disorder:
What To Do For A Loved One:
First, in order to understand what our loved one is going through we must understand how their personality disorder functions. Education and understanding is key for a relationship with someone who has AvPD.
It doesn’t make you a bad person to feel annoyance or displeasure, you may feel frustrated at their irrational behavior. You may feel the pressure to choose between caring for the person who is behaving in an avoidant way and your desire for healthy social interaction. You may feel pressured to become a hermit with them, and begin to resent that pressure.
Detach yourself emotionally from any dysfunctional attitudes. You don’t have to agree with them and you don’t have to fight with them. You can agree to disagree.
Maintain healthy outside interests, recreational pursuits and supportive relationships.
Get support from people who understand personality disorders. Join a support group.
What Not To Do For A Loved One:
Don’t blame yourself for the avoidant behavior and attitudes of a loved one. This isn’t and never will be your fault.
Don’t give in to pressure to isolate yourself from healthy relationships. The pressure may be particularly strong to give in and begin to isolate yourself as much as your loved one. This is nor fair to you, your social life, and your way of life. Keep up with your relationship with others at all cost.
Don’t try to “thought police” the person with the personality disorder. Thought Policing is a term used to describe the assumption that they know exactly what another person is thinking. You’re not omniscient (probably) and sometimes, no matter how well you know the person, you will make an assumption that hurts your loved one.
Don’t try to control their behavior – focus on being healthy yourself. It’s not worth it to tangle yourself up trying to control the behavior of your loved one, you can’t do it, it won’t work, and you too need to be healthy.
Additional Resources for Avoidant Personality Disorder
Out of the Fog – information and support for those with a loved one suffering any type of personality disorder.
Avoidant Personality Disorder – Support group and website devoted to people with Avoidant Personality Disorder and those who love them.