Avoidant Personality Disorder Resources

by Aunt Becky | May 9, 2019

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.

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 style:

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
• Hypersensitivity
• 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
• Shyness

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 factors:

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:

Lynn E. Alden and Martha J. Capreol, in 1993, proposed two other subtypes of avoidant personality disorder:

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

Differential Diagnosis: 

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.

Histrionic Personality Disorder

by Aunt Becky | May 7, 2019

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 behaviors.

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 Histrionic Personality Disorder?

Histrionic Personality Disorder (HPD) is a personality disorder characterized by a pattern of extreme, intense emotions as well as attention-seeking behavior. A person who has histrionic personality disorder needs to be the center of attention in a group – any group – and when they are not, they become upset and uncomfortable. Histrionic personality disorder (HPD) also majorly interferes with emotional stability, and are prone to emotional overreaction in a wide variety of situations, and from the viewpoint of others, they may seem constantly on edge. When they do react, it is usually from a self-centered perspective, and the needs of others are seldom their priority.

In addition to the extremes of their emotional sensitivity and reactivity, people with histrionic personality disorder have a strong need to be the center of attention and frequently exhibit a range of attention-seeking behavior. They also want instant satisfaction and are easily frustrated or overwhelmed by obstacles or criticism. People with HPD usually have good communication skills and are often quite charismatic, projecting a “life of the party” or “larger than life” image. But beyond good initial first impressions they have a difficult time establishing and maintaining close and satisfying relationships.

Despite their self-absorption, people with HPD are subsumed by insecurity, which usually leaves them frustrated and miserable and seeking answers for their feelings of inadequacy.

HPD is classified as a Cluster B personality disorder, along with borderline personality disorder, narcissistic personality disorder, and antisocial personality disorder. People with Cluster B conditions are known to be highly emotional, erratic in their feelings and behavior, and self-centered in their approach to socializing and building relationships.

Nearly 15 percent of the American population meet the diagnostic criteria for one or more of 10 recognized personality disorders. Histrionic personality disorder is one of the least common of these personality disorders, affecting about 1.8 percent of the population – which still represents about four million people. Histrionic personality disorder is diagnosed more frequently among women, who comprise about two-thirds of the known cases. This may not reflect the true incidence of the disorder, but could relate to the willingness of women (or unwillingness of men) to seek assistance for the symptom of HPD when they manifest.

The seeds of histrionic personality disorder are likely sown in childhood, but its symptoms don’t normally become apparent until late adolescence. The severity of the condition may then escalate during early adulthood and become a dominant factor from that point on.

Those with histrionic personality disorder need novelty and thrills, which may lead them to become bored with the usual routines. This may lead to frustration when gratification is delayed, as they want immediate satisfaction. Interest in jobs, friendships, and relationships may quickly dwindle in favor of the shiny newness of other relationships.

Someone with histrionic personality disorder often appears as effervescent, lively, and interesting (sometimes shallow), and cannot handle it when the attention is not focused entirely upon them. In order to direct attention back to themselves, they may begin sexually suggestive or seductive behavior. Despite being highly sexual, people with histrionic personality disorder often have problems with emotional intimacy in sexual or romantic relationships.

Whether or not they are aware, they often choose a role (victim, princess) within their relationships. People with histrionic personality disorder may try to control their partner through seductiveness or emotional manipulation while displaying a strong dependency on their partners on another level. Because people with histrionic personality disorder crave excitement and newness, longer-term relationships are difficult for them to maintain.

It’s hard for those with histrionic personality disorder to maintain same-sex friendships because their sexually-charged style may come across as a threat to their friends’ romantic relationships. In addition, people with histrionic personality disorder can alienate friends through their demands for constant attention, and their depression when that attention is not provided.

What Are The Core Features of Personality Disorders?

The general requirements for the diagnosis of a personality disorder are:

• a pervasive pattern of maladaptive traits and behavior
• beginning in early adult life
• it usually has its first manifestations in childhood and is clearly evident in adolescence
• it is not diagnosed before early adult life because these maladaptive traits are very common in childhood and adolescence, but most individuals age-out of these traits before early adulthood
• leading to substantial personal distress and/or social dysfunction, and disruption to others
• is of long duration, typically lasting at least several years
• Severity Rating Scale For Personality Disorders:

Severity rating scale for personality disorders in the International Classification of Diseases (ICD)-11:

Mild Personality Disorder: notable problems in many interpersonal relationships and the performance of expected work and social etiquette, but some relationships are maintained and/or some roles carried out. Mild personality disorder is typically not associated with substantial harm to self or others.

Moderate Personality Disorder: marked problems in most interpersonal relationships and in the performance of expected occupational and social roles across a wide range of situations that are sufficiently extensive that most are compromised to some degree. Moderate personality disorder often is associated with a past history and future expectation of harm to self or others, but not to a degree that causes long-term damage or has endangered life.

Severe Personality Disorder: There are severe problems in interpersonal functioning affecting all areas of life. The person’s general social dysfunction is profound and the ability and/or willingness to perform expected occupational and social roles is absent or severely compromised. Severe personality disorder usually is associated with a past history and future expectation of severe harm to self or others that has caused long-term damage or has endangered life.

HPD is a serious condition that isolates those who surround the people who have the disorder.

A mnemonic that has sometimes been used to describe the criteria for histrionic personality disorder is “PRAISE ME”:

 

 

 

 

 

 

 

 

P – provocative (or seductive) behavior
R – relationships, considered more intimate than they are
A – attention, must be at center of
I – influenced easily
S – speech (style) – wants to impress, lacks detail
E – emotional liability, shallowness

M – make-up – physical appearance used to draw attention to self
E – exaggerated emotions – theatrical

However, people who suffer from HPD are often just as interested in attracting negative attention, including shock, anger, outrage, shame, guilt and remorse.

What Causes Histrionic Personality Disorder?

What Are Symptoms of Histrionic Personality Disorder? 

While people with Histrionic Personality Disorder are able to function at a high-level and be socially successful, they often use these skills to manipulate others and become the center of attention.

Personality disorders generally are marked by an obsessive concern for the self, rigid and uncompromising attitudes, and an inability or unwillingness to adapt to the needs and desires of others. These disorders function as a cover for deep-seated self-esteem issues, representing a form of overcompensation for feelings of insecurity and inferiority.

An accurate histrionic definition focuses on the distinctive symptoms HPD produces, which include:

• Strong and volatile emotions, both negative and positive
• Rapid shifts in mood, often triggered by seemingly benign events
• Self-centeredness, in conversation and behavior
• Exaggerated gestures or words designed to draw attention
• Expressions of sentiments toward others that seem shallow or insincere, as if meant to manipulate or create a certain impression
• Grossly exaggerated emotional displays
• Believe that their relationships are fa more intimate than they are
• A lack of patience, often accompanied by childish reactions
• Tendency to become flustered or frustrated when things go wrong
• Extreme sensitivity to criticism or perceived rejection
• Constant approval-seeking behavior
• Constant reassurance-seeking behaviors
• Flirtatious or sexually suggestive behavior that may violate interpersonal boundaries
• Exhibition-type behaviors
• Unwillingness to change; suggestions of change are viewed as threats
• Obsessive concern with physical appearance
• A tendency to become bored or distracted, making it difficult to finish tasks or projects
• Lack of empathy, no capacity to read the emotions of others or correctly interpret their words and actions
• Inability to maintain satisfying relationships due to self-centered tendencies and emotional outbursts

Many of these symptoms are common to other personality disorders, which inevitably interfere with personal, social, and professional functioning.

What Are Some Of The Traits Of Those Who Have HPD?

The following list is a collection of some of the more commonly observed behaviors and traits of those who suffer from HPD. Note that these traits are given as a guideline only and are not intended for diagnosis. People who suffer from HPD are all unique and so each person will display a different subset of traits. Also, note that everyone displays “borderline” 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 HPD. See the DSM Criteria on this page for diagnostic criteria.

Catastrophizing – The habit of automatically assuming a “worst case scenario” and inappropriately characterizing minor or moderate problems or issues as catastrophic events.

Chaos Manufacture – Unnecessarily creating or maintaining an environment of risk, destruction, confusion or mess.

Baiting – A provocative act used to solicit an angry, aggressive or emotional response from another individual.

Acting Out – Acting Out behavior refers to a subset of personality disorder traits that are more outwardly-destructive than self-destructive.

“Always” and “Never” Statements – “Always” and “Never” Statements are declarations containing the words “always” or “never.” They are commonly used by most people but arerarely true.

Anger – People who suffer from personality disorders often feel a sense of unresolved anger and a heightened or exaggerated perception that they have been wronged, invalidated, neglected or abused.

Belittling, Condescending, and Patronizing – This kind of speech is a passive-aggressive approach to giving someone a verbal put-down while maintaining a facade of reasonableness or friendliness.

Blaming – The practice of identifying a person or people responsible for creating a problem, rather than identifying ways of dealing with the problem.

Cheating – Sharing a romantic or intimate relationship with somebody when you are already committed to a monogamous relationship with someone else.

Circular Conversations – Arguments which go on almost endlessly, repeating the same patterns with no resolution.

Confirmation Bias – The tendency to pay more attention to things which reinforce your beliefs than to things which contradict them.

Denial – Believing or imagining that some painful or traumatic circumstance, event or memory does not exist or did not happen.

Dependency – An inappropriate and chronic reliance by an adult individual on another individual for their health, subsistence, decision making or personal and emotional well-being.

Depression – People who suffer from personality disorders are often also diagnosed with symptoms of depression.

Dissociation– A psychological term used to describe a mental departure from reality.

Emotional Abuse – Any pattern of behavior directed at one individual by another which promotes in them a destructive sense of Fear, Obligation or Guilt (FOG).

Emotional Blackmail – A system of threats and punishments used in an attempt to control someone’s behaviors.

Engulfment – An unhealthy and overwhelming level of attention and dependency on another person, which comes from imagining or believing one exists only within the context of that relationship.

Escape To Fantasy – Taking an imaginary excursion to a happier, more hopeful place.

False Accusations – Patterns of unwarranted or exaggerated criticism directed towards someone else.

Favoritism and Scapegoating – Systematically giving a dysfunctional amount of preferential positive or negative treatment to one individual among a family group of peers.

Fear of Abandonment – An irrational belief that one is imminent danger of being personally rejected, discarded or replaced.

Feelings of Emptiness – An acute, chronic sense that daily life has little worth or significance, leading to an impulsive appetite for strong physical sensations and dramatic relationship experiences.

Frivolous Litigation – The use of unmerited legal proceedings to hurt, harass or gain an economic advantage over an individual or organization.

Harassment – Any sustained or chronic pattern of unwelcome behavior by one individual towards another.

Holiday Triggers – Mood Swings in Personality-Disordered individuals are often triggered or amplified by emotional events such as family holidays, significant anniversaries and events which trigger emotional memories.

Hoovers & Hoovering – A Hoover is a metaphor taken from the popular brand of vacuum cleaners, to describe how an abuse victim trying to assert their own rights by leaving or limiting contact in a dysfunctional relationship, gets “sucked back in” when the perpetrator temporarily exhibits improved or desirable behavior.

Hysteria – An inappropriate over-reaction to bad news or disappointments, which diverts attention away from the real problem and towards the person who is having the reaction.

Identity Disturbance – A psychological term used to describe a distorted or inconsistent self-view

Impulsiveness – The tendency to act or speak based on current feelings rather than logical reasoning.

Invalidation – The creation or promotion of an environment which encourages an individual to believe that their thoughts, beliefs, values or physical presence are inferior, flawed, problematic or worthless.

Lack of Conscience – Individuals who suffer from Personality Disorders are often preoccupied with their own agendas, sometimes to the exclusion of the needs and concerns of others. This is sometimes interpreted by others as a lack of moral conscience.

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 – A common name for a negatively-distorted self-view which is inconsistent with reality.

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.

Mood Swings – Unpredictable, rapid, dramatic emotional cycles which cannot be readily explained by changes in external circumstances.

“Not My Fault” Syndrome – The practice of avoiding personal responsibility for one’s own words and actions.

No-Win Scenarios – When you are manipulated into choosing between two bad options

Panic Attacks – Short intense episodes of fear or anxiety, often accompanied by physical symptoms, such as hyperventilating, shaking, sweating and chills.

Push-Pull – A chronic pattern of sabotaging and re-establishing closeness in a relationship without appropriate cause or reason.

Raging, Violence and Impulsive Aggression – Explosive verbal, physical or emotional elevations of a dispute. Rages threaten the security or safety of another individual and violate their personal boundaries.

Relationship Hyper Vigilance – Maintaining an unhealthy level of interest in the behaviors, comments, thoughts and interests of others.

Riding the Emotional Elevator – Taking a fast track to different levels of emotional maturity.

Sabotage – The spontaneous disruption of calm or status quo in order to serve a personal interest, provoke a conflict or draw attention.

Selective Memory and Selective Amnesia – The use of memory, or a lack of memory, which is selective to the point of reinforcing a bias, belief or desired outcome.

Selective Competence – Demonstrating different levels of intelligence, memory, resourcefulness, strength or competence depending on the situation or environment.

Self-Aggrandizement – A pattern of pompous behavior, boasting, narcissism or competitiveness designed to create an appearance of superiority.

Self-Harm – Any form of deliberate, premeditated injury, such as cutting, poisoning or overdosing, inflicted on oneself.

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.

Sense of Entitlement – An unrealistic, unmerited or inappropriate expectation of favorable living conditions and favorable treatment at the hands of others.

Silent Treatment – A passive-aggressive form of emotional abuse in which displeasure, disapproval and contempt is exhibited through nonverbal gestures while maintaining verbal silence.

Situational Ethics – A philosophy which promotes the idea that, when dealing with a crisis, the end justifies the means and that a rigid interpretation of rules and laws can be set aside if a greater good or lesser evil is served by doing so.

Splitting – The practice of regarding people and situations as either completely “good” or completely “bad.”

Stunted Emotional Growth – A difficulty, reluctance or inability to learn from mistakes, work on self-improvement or develop more effective coping strategies.

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.

Threats – Inappropriate, intentional warnings of destructive actions or consequences.

Triggering -Small, insignificant or minor actions, statements or events that produce a dramatic or inappropriate response.

Tunnel Vision – The habit or tendency to only see or focus on a single priority while neglecting or ignoring other important priorities.

What Other Mental Health Disorders Occur In People Who Have HPD?

It is possible for a person to have the symptoms of more than one personality disorder as these disorders often blend into one another.

Among people diagnosed with HPD, borderline personality disorder, dependent personality disorder, and narcissistic personality disorder are also frequently diagnosed. Borderline personality disorder is the most commonly detected of these conditions, and some mental health professionals actually classify HPD as a borderline personality disorder subtype.

Some of the other mental and behavioral health disorders routinely diagnosed in people with histrionic personality disorder include:

• Depression. HPD creates strong emotional responses, and when rejection or disappointment is experienced people with histrionic personalities can easily slip into clinical depression.
• Anxiety disorders, including panic disorder. In one study, between 35 and 52 percent of those with various anxiety disorders also met the diagnostic criteria for a personality disorder, usually of a type that affects emotion and stress responses (such as HPD)
• Somatoform Disorders
• Attachment Disorders, such as reactive attachment disorder
• Eating disorders. About one-third of eating disorder sufferers also have one or more co-occurring personality disorders, often including HPD.
• Substance use disorders. While different studies have produced varying results, most research has shown as least some relationship between histrionic personality disorder and addiction. However, the association is not as strong as with several other types of personality disorder.

When an additional mental or behavioral health condition is diagnosed in people with HPD, treatment plans must be developed that focus equally on each disorder.

How is Histrionic Personality Disorder Diagnosed?

HPD is not a devastating psychological disorder, which means that people with this disorder rarely seek treatment as most people with HPD function successfully in society and at work. In fact, people with HPD usually have great people skills. unfortunately, however, they often use these skills to manipulate others.

According to the Diagnostic and Statistical Manual of Mental Disorders (5^th edition), people with histrionic personality disorder must have at least five (or more) of the following symptoms:

• Is uncomfortable in situations in which they are not the center of attention
• Has interactions with others characterized by inappropriate sexually seductive or provocative behavior
• Displays rapidly shifting and shallow expression of emotions
• Consistently uses their physical attention to draw attention to self
• Has a style of speech that is excessively impressionistic and lacking in detail
• Shows self-dramatization, theatricality, and exaggerated expression of emotion
• Is suggestible (that is, they are easily influenced by others or circumstances)
• Considers relationships to be more intimate than they actually are

If you have HPD, you might also be easily frustrated or bored with routines, make rash decisions before thinking, or threaten to commit suicide in order to get attention.

The World Health Organization’s ICD-10 lists histrionic personality disorder as:

A personality disorder characterized by:

• shallow and labile affectivity,
• self-dramatization,
• theatricality,
• exaggerated expression of emotions,
• suggestibility,
• egocentricity,
• self-indulgence,
• lack of consideration for others,
• easily hurt feelings, and
• continuous seeking for appreciation, excitement and attention.

It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfies a set of general personality disorder criteria.

A diagnosis of histrionic personality disorder occurs through a thorough examination by a psychiatrist or psychologist by reviewing symptoms and taking a detailed health history. If the symptoms meet the diagnostic criteria, a diagnosis of histrionic personality disorder is made.

What Are The Subtypes for Histrionic Personality Disorder?

Histrionic Personality Disorder Subtypes (As Suggested by Million)

Subtypes of HPD	Description	Personality Qualities
Infantile HPD	includes borderline PD symptoms	Labile, high-strung, volatile emotions; childlike hysteria and nascent pouting; demanding, overwrought; fastens and clutches to another; is excessively attached, hangs on, stays fused to and clinging.
Vivacious Histrionic	The seductiveness of the histrionic mixed with the energy typical of hypomania. Some narcissistic features may also be present	Vigorous, charming, bubbly, brisk, spirited, flippant, impulsive; seeks momentary cheerfulness and playful adventures; animated, energetic, ebullient.
Tempestuous histrionic	Includes passive aggressive PD	Impulsive, out of control; moody complaints, sulking; precipitous emotion, stormy, impassioned, easily wrought-up, periodically inflamed, turbulent.
Appeasing histrionic	Includes compulsive and depended PD	Seeks to placate, mend, patch up, smooth over troubles; knack for settling differences, moderating tempers by yielding, compromising, conceding; sacrifices self for commendation; fruitlessly placates the unplacatable.
Disingenuous histrionic	HPD and antisocial PD	Underhanded, double-dealing, scheming, contriving, plotting, crafty, false-hearted; egocentric, insincere, deceitful, calculating, guileful.
Theatrical histrionic	Variant of “pure” pattern	Affected, mannered, put-on; postures are striking, eyecatching, graphic; markets self-appearance; is synthesized, stagy; simulates desirable/dramatic poses.

How Is Histrionic Personality Disorder Treated?

Those who suffer Histrionic Personality Disorder are generally hard to treat for many reasons. People with HPD often only seek treatment when their symptoms have become too much for them to handle. Once in treatment, however, these people often exaggerate their symptoms and lack of ability to function. They also have a hard time, as they are emotionally needy, terminating therapy may become a problem.

If people who have HPD are truly determined to change their emotional and psychological reactions, HPD can be amenable to treatment.

Inpatient or intensive outpatient treatment programs in mental health treatment facilities are ideal for people diagnosed with HPD, who require peace, quiet, and ample social and psychological support in the early stages of recovery.

Psychotherapy is the preferred method of intervention for histrionic personality disorder. Some of the therapies that have proven effective for this condition include:

• Cognitive behavioral therapy (CBT). Through CBT people with histrionic personalities can begin to think and act more calmly and with more deliberation and contemplation. CBT is also effective against depression and anxiety disorders, which can co-occur with HPD.
• Interviews and self-report methods generally, in clinical practice with assessment of personality disorders, one form of interview is the most popular; an unstructured interview. The actual preferred method is a semi-structured interview. The reason that a semi-structured interview is preferred over an unstructured one is that semi-structured interviews tend to be more objective, systematic, replicable, and comprehensive. Unstructured interviews, despite popularity, tend to have problems with unreliability and are susceptible to errors leading to false assumptions of the client. One of the single most successful methods for assessing personality disorders by researchers of normal personality functioning is the self-report inventory following up with a semi-structured interview. There are some disadvantages with the self-report inventory method that with histrionic personality disorder there is a distortion in character, self-presentation, and self-image. This cannot be assessed simply by asking most clients if they have the criteria for the disorder.
• Psychodynamic therapy. The goal in psychodynamic therapy is to decrease emotional reactivity by identifying and demystifying the underlying reasons for the development of HPD.
• Family and couples therapy. Family therapy should be explored only after the person with HPD has done some hard work on him or herself; otherwise, the person with HPD is apt to dominate all conversations
• Holistic mind-body practices. Mindfulness techniques acquired through meditation, yoga, Tai Chi, biofeedback, and other holistic therapies have much to offer people with HPD, who need to reprogram their minds to more effectively control their hair-trigger emotional reflexes.
• Medications are not indicated for treatment of histrionic personality disorder, though they may be used to treat some of the symptoms and/or other, co-morbid, disorders.
• Self-help groups and/or group therapy is not effective for those who have HPD as they are prone to hysterics and outbursts

With careful and compassionate intervention that extends from initial treatment through aftercare, people with histrionic personality disorder can learn to minimize the condition’s influence on their lives. HPD cannot be cured, but over time its capacity to control emotional reactions can be reduced to a manageable level.

Coping With Histrionic Personality Disorder:

Lots of people with HPD lead normal lives and are able to work and be a part of society. In fact, many people with HPD do very well in casual settings. Many of them only encounter problems in more intimate relationships. Depending on your case, your HPD may affect your ability to hold a job, maintain a relationship, or stay focused on life goals. It may also cause you to constantly seek adventure, putting you into risky situations.

You are also at a higher risk for depression if you have HPD. The disorder can affect how you handle failure and loss. It can also leave you feeling more frustrated when you don’t get what you want. You should talk to your primary care provider if you have symptoms of HPD, especially if they are interfering with your everyday life and work or your ability to lead a happy, fulfilling life.

Loving Someone With Histrionic Personality Disorder:

It is exhausting to deal with a person who has this personality disorder as they are particularly demanding – which is part of the disorder. Sometimes, it may be possible to stop being around such a person and extricate oneself from the situation, in other cases, especially where family members are concerned, that is never a choice. Then what is one to do and how is one to keep the relation going?

Sometimes, people with HPD may be abusive. You are not obligated to spend time with an abusive person, and you have the right to distance yourself or cut contact altogether. Do what’s right for you.

Here are some ideas for dealing with a person who has histrionic personality disorder:

Establish And Maintain Boundaries:

Create realistic goals. Histrionic personality disorder is a complicated disorder, and there may be limited things that you can do to help your loved one. Therefore, realistic goals are incredibly important when you decide to help them.You must understand that you may never be able to help them with their condition.  Create some safe space between you for your own self care. You must take care of your self.

• Help your loved one set their own goals. For example, you may want to help them set goals related to the way they dress, the types of sexual relationships they have, or the amount of times they act out in a dramatic or theatrical way.

Set limits and stick to them. When your loved one has Histrionic Personality Disorder, you need to establish strict boundaries for your relationship. Your loved one may engage in attention-seeking, manipulative, or embarrassing behavior at any time, which does directly affect you. Try to have an open, honest discussion with them about your personal limits.

• For example, tell your loved one, “If you start manipulating me, I will leave” or “If you start acting out or embarrassing yourself to get attention, I will leave” and stick with this plan.

Make sure they know that you still love them. A relationship with a loved one with HPD can be complicated and tense as this personality disorder can cause major problems that cause hurt feelings and complicated, strained relationships. You should try to your loved one know that you still love them, even though you have limits and may sometimes leave, you still love and care for them.

• You can tell them, “I love you and want you in my life. However, there are times I cannot be around you because of your behavior.”

Know how and when to distance yourself. You may find yourself in a situation where your loved one is being manipulative, cruel, hurtful, embarrassing, or harmful which can be overwhelming to you. People with HPD often do anything to be the center of attention; including manipulation, acting dramatically, and love to play the victim. They may act in an overly provocative way, or act out in a hateful or angry way to gain attention. As you know, all of this can negatively affect you. Be aware that you may have to distance yourself from your loved one to protect yourself and your own well-being.

• Some people just aren’t equipped to help a person with HPD. Be aware that as a last resort, you may have to completely remove yourself from the situation and sever all ties.

Taking Care of Yourself:

Consider seeing a therapist. Talking with a therapist about your challenges and feelings regarding your loved one’s histrionic personality disorder is a good way to care for yourself. A therapist can help you to develop healthy coping mechanisms, learn how to communicate with your loved one more effectively, and work through your emotions. Consider talking to a therapist as part of your self-care strategy.

Seek help from your friends and family. Dealing with a loved one with HPD can be an emotionally exhausting rollercoaster and you may feel helpless, trapped, and/or confused. Find support from your loved ones when you need it, and ensure that you make time to be away from your loved one, and instead, visit and interact with others. This can help you feel supported.

• Talk to your friends and family about your difficulties. You can even ask them for advice if things get too much to bear.

Don’t let your loved one to dictate your other relationships. Because people with HPD often feel inadequate or inferior, they may throw fits or act in an over-dramatic way when you form relationships and spend time with other people. You cannot let the person with HPD dictate your other relationships.

• Your loved one may see another friend, partner, or even child as a threat. Discourage this behavior. Don’t give into any behavior in which your loved one tries to discourage the relationship.
• For instance, you can say, “I have friends and invite them over once in a while. This does not affect my love for you.”
• Your loved one may get jealous or threatened by you participating in activities that don’t include them. Refrain from giving up activities because of your loved one’s HPD.

Come to terms with the idea that your loved one may never understand your needs. People with HPD appear to be self-centered, which means that they may not understand or respect your needs, even if you have clearly outlined them. People who hav do not realize their actions are wrong, or how their actions affect other people.

• You may need to accept that your loved one will never treat you how you deserve to be treated. This is why setting boundaries and limits in the relationship is so important.

How To Cope With HPD:

Don’t make excuses. If your loved one has HPD, you may find yourself wanting to make excuses for their behavior, cover up their behavior, or clean up any messes they have made. This is not your job, and can take a toll on you. Try not to make excuses or mediate any messes your loved one has made. This may just enable your loved one’s behavior.

• Your loved one’s behavior may be humiliating for you. However, learning to walk away or detach yourself may be the best way to take care of yourself.

Avoid trying to teach your loved one a lesson. Sometimes, loved ones of those with HPD abandon the person to teach them some sort of lesson. This can arise when the person with HPD manipulates you too much or you feel nothing that you do is working. This kind of punitive behavior does not work with people with HPD, so you should avoid the temptation.

• • If you do this, your loved one may feel abandoned and throw a dramatic fit since you abandoned them.
  • You may end up feeling helpless and manipulated if you try to use this kind of manipulation on your loved one. Avoid using games with your loved one. Stay direct and open with them instead.

Don’t reward attention-seeking behavior. Your loved one may engage in dramatic, attention-seeking behavior regularly, and one of the best ways to deal with this is to ignore it. Don’t engage with them when they are acting like this, it will further reinforce the negative behavior with attention.

• Your loved one likely has a chemical imbalance, which means they may not be able to help their behavior. Instead of getting into an argument or encouraging behavior, just ignore it and let it pass.

Remain calm. One of the best things you can do to help your loved one is to stay calm. A person with Histrionic Personality Disorder thrives on chaos and drama, if/when they get dramatic or have a fit, reacting to them in a negative way will play into what they want and encourage the behavior. Instead, remain calm during these fits.

• You may need to engage in deep breathing exercises or step away from your loved one for a few moments to collect yourself.

Put physical distance between you and your loved one. People with HPD form intimate attachments very easily, which means they may cross physical boundaries. They may not be able to understand or respect the boundaries you have set for yourself. You may find your loved one hugs you, touches you, or invades your space more than you wish. Your loved one may interpret your actions as threatening or inappropriate. To help with this, keep physical distance between you and them.

• For example, you may want to sit in a chair if your loved one is on the couch, or sit on the other end of the couch. When standing, keep a few feet between you and your loved ones.
• Be mindful not to do anything that might be suggestive or interpreted as inappropriate. You don’t want your loved one to misinterpret what you are doing. Always be mindful of your boundaries.

Encourage your loved one to evaluate and think about what other people say. Some people who have HPD are highly suggestible and will go along with what other people say without enforcing their own boundaries and desires. If you notice that your loved one is blindly agreeing with people or doing what other people tell them to do, try to encourage your loved one to think for him or herself.

• If you notice that your loved one is agreeing with someone without evaluating the statement, you could try asking some questions to help you loved one evaluate what the person said.
  • For example, your loved one might repeat a political opinion as a fact because they heard someone else say it. You could then ask your loved one questions like, what is the evidence for that? How did they come to that conclusion? Why do you agree with them?
• If your loved one is doing something because someone has suggested it, then you can also use questioning to help.
  • For example, your loved one might start dressing differently because someone suggested it. You might ask your loved one questions like, do you really want to do that? Would you be doing that if he or she had not suggested it? What might you be doing if he or she had not suggested that?

Suggest different clothing for your loved one. One of the main symptoms of HPD is wearing provocative clothing to garner attention. This type of attire is not suitable for all situations, such as work. You can help your loved one by suggesting they dress differently for certain situations.

• Make sure to start any suggestion with a compliment. Those with HPD respond extremely negatively to any criticism. By complimenting them, you can help yourself get a positive response.
• For example, you may say, “I really love that outfit. You should wear that tomorrow night when you go out with your friends! Why don’t you wear this to work instead today? It looks great on you, and everyone will think you look classy.”

Ask for support when your loved one states their opinion. Often, people with HPD will just talk or argue because they like the attention and drama. They may offer strong opinions while offering no support. When this happens, ask your loved one to back up their opinion.

• For example, you may say, “What are you basing that opinion on?” or “Do you have any examples to support your opinion?” You may also say, “That doesn’t sound like a correct statement. Can you give me some evidence to support your position?”
• If your loved one cannot support their opinion, explain that they need to only provide opinions based on facts or details. Encourage research issues so they can make informed opinion

Help your loved one come up with solutions. Often, people with HPD ignore solutions in favor of focusing on the drama of the problem. One way you can try to help your loved one is by encouraging them to come up with solutions and focus on problem-solving techniques instead of the problem.

• For example, when your loved one gets dramatic about a problem, listen to what they say about the problem. Then say, “I understand you have a problem, but dwelling on it will not help you or anyone else. Let’s work together to find a solution.”

Explore other things. To help keep your loved one’s attention-seeking or manipulative behavior to a minimum, you should talk about or do other things with them. Don’t let your loved one dwell on problems or dominate the spotlight. Talk about yourself or suggest that the two of you do an activity together.

• • For example, you may want to say, “We have been talking about you for a long time now. I would like to share with you things about my life.”
  • You can try to distract your loved one if they are in a middle of an attention-seeking or manipulative episode. You can change the subject, start watching television, or suggest that you go for a walk or to a movie.

Communication With Your Loved One:

Try empathizing with them, then set a limit. People with HPD may feel sensitive to rejection, because they’re deeply insecure. Helping them label their feelings allows them to better understand how they’re feeling, and know that you aren’t rejecting them (just asking them to stop doing something).

• • • “I get that you’re feeling lonely. But faking an injury isn’t a healthy way to get attention. If you want, we could do something simple together, like taking a walk or playing a board game.”
    • “I know you’re excited to be with friends. Please remember to let Jamal talk, too.”
    • “I can tell that you’re upset. I’m exhausted, though, and I don’t have the energy to talk about it. Could you call your sister, or talk to me in the morning?”

Try labeling their behaviors. People with HPD report being somewhat oblivious to their destructive habits, meaning that they may not realize when they are out of line. Make an observation or question about what they’re doing. This encourages them to step back and re-evaluate what they’re doing.

• • • “You’re spiraling.”
    • “Are you trying to manipulate me?”
    • “It looks like you’re starting something self destructive.”
    • “Honey, you’re making it about you again.”

Remind them of the consequences of what they’re doing. People with HPD may not think things through, or realize that their actions could have destructive consequences. Calmly remind them of what could happen if they act, or keep acting, a certain way.

• • • “You’re making me uncomfortable. If you keep doing this, I will leave.”
    • “This is John’s special day. If you do that at his party, he’ll feel really hurt and upset.”
    • “You could get seriously hurt if you do that.”
    • “When you do this, it makes me not want to spend time with you.”

Express feelings and boundaries clearly and calmly. People with HPD can benefit from explicit boundaries and reminders. Try using “I” language to explain how their behavior makes you feel. This can serve as a warning so that they can slow down and think.

• • • “When you ______, I feel ______. Because of this, _________.”
    • “Please, stop interrupting me. I’m getting frustrated.”
    • “That really hurt my feelings.”
    • “You’re embarrassing me. It makes me want to leave.”

Follow through with consequences if your loved one doesn’t heed your warning. They need to know that when you set boundaries, you mean what you say.

• • • For example, if you say that you’re going to leave if they keep doing something, and they keep doing it, then leave.

Talk about inappropriate behavior, without criticizing them personally. People with HPD act out because they feel insecure, and you don’t want to be cruel or make things even worse. Talk about their behavior, and the consequences of their behavior, without labeling them as selfish or bad. This helps them re-examine their actions and learn from them.

• • • Unhelpful: “You’re such a drama queen! I can’t deal with you anymore! I’m never taking you anywhere again.”
    • Helpful: “I’m disappointed and embarrassed that you flirted with my boss, even after I asked you to stop. It makes me not want to take you to work parties anymore, because I don’t know how to deal with this.”
    • Unhelpful: “You’re so embarrassing! If you don’t stop being like this, you’ll end up sad and alone.”
    • Helpful: “You really embarrassed me in the grocery store today. Now I feel bad, and I don’t know what I’ll do next time I see Mrs. Martinez in public.”

Helping Your Loved One Get Treatment for HPD:

Encourage treatment. The best way a person with HPD can get better is through treatment. However, most people with HPD either don’t seek treatment or they only stay in treatment for a short period of time. You should encourage your loved one to get treatment. If they are already seeking treatment, help encourage them to continue treatment, even when they get bored or want to quit.

• • • “I love you, and your behavior is hurting yourself and me. Would you be willing to get treatment?”
    • “I know you feel that treatment is no longer exciting or that you are better, but this is a major condition that cannot be fixed quickly. Will you please reconsider going back to treatment?”

Help them get psychotherapy. Psychotherapy is the most effective treatment for HPD. This includes talking with a therapist who can use different therapeutic approaches to help your loved one, such as cognitive behavioral therapy. Most people with HPD don’t continue with their therapy after beginning because they lose interest, think they are better, or are too impulsive to follow through with their treatment.

• Cognitive behavioral therapy can address problematic behaviors, such as impulsive actions, manipulative behaviors, and theatrics.

Seek treatment for underlying conditions. Often, people with HPD also have other, co-occurring disorders, such as depression. Because of their feelings of insecurity, inadequacy, and abandonment, they may feel depressed and need to be treated for this.

• If this is the case, your loved one can take selective serotonin reuptake inhibitors (SSRIs) to treat the depression, which may help their overall mood. SSRIs are common in the treatment of depression, and include medications such as Zoloft, Celexa, and Prozac.

Keep watch for destructive behavior. Histrionic personality disorder may lead to self-destructive behavior. People with HPD often exhibit suicidal behavior or behavior leading to self-harm. The person may just be threatening these behaviors to gain attention, so you need to make a decision about the seriousness of the threat.

• Some people with HPD will harm themselves or try to commit suicide to gain attention. Try to notice when your loved one is getting to this destructive stage.
• People with HPD may also exhibit dangerous behavior towards others. Watch your loved one to see if they exhibit any tendencies to hurt those around them