By Mark Zimmerman, MD, Rhode Island Hospital
Avoidant personality disorder is characterized by the avoidance of social situations or interactions that involve a risk of rejection, criticism or humiliation. Diagnosis is by clinical criteria. Treatment is with psychotherapy, anxiolytics and antidepressants.
(See also Overview of Personality Disorders.)
People with avoidant personality disorder have intense feelings of inadequacy and deal maladaptively by avoiding any situations in which they might be negatively evaluated.
The reported prevalence of avoidant personality disorder in the US varies, but the estimated prevalence is about 2.4%. Avoidant personality disorder affects men and women in equal proportions.
Comorbidities are common. Patients often also have major depressive disorder, persistent depressive disorder, obsessive-compulsive disorder, or anxiety disorder (eg, panic disorder, particularly social phobia [social anxiety disorder]). They may also have another personality disorder (eg, dependent, borderline). Patients with social phobia and avoidant personality disorder have more severe symptoms and disability than those with only one of the disorders.
Etiology of avoidant personality disorder
Research suggests that childhood experiences of rejection and marginalization and innate characteristics of social anxiety and avoidance may contribute to avoidant personality disorder. Avoidance in social situations was detected as early as 2 years of age.
Signs and symptoms of avoidant personality disorder
Patients with avoidant personality disorder avoid social interaction, including those at work, because they fear they will be criticized or rejected or that people will disapprove of them, as in the following situations:
• They may turn down a promotion because they fear co-workers will criticize them.
• They can avoid meetings.
• They avoid making new friends unless they are sure they will be approved.
These patients assume that people will be critical and will disapprove of them until they undergo rigorous testing proving otherwise. Thus, before joining a group and forming an intimate relationship, patients with this disorder require repeated reassurances of support and uncritical acceptance.
Patients with avoidant personality disorder crave social interaction but fear putting their well-being in the hands of others. Because these patients limit their interactions with people, they tend to be relatively isolated and don't have a social network that can help them when they need it.
These patients are very sensitive to anything mildly critical, disapproval, or ridicule because they constantly think about being criticized or rejected by others. They are on the lookout for any sign of a negative response to them. Your tense and anxious appearance may provoke mockery or ridicule, thus seeming to confirm your self-doubts.
Low self-esteem and a sense of inadequacy inhibit these patients in social situations, especially new ones. Interactions with new people are inhibited because patients consider themselves socially inept, unpleasant, and inferior to others. They tend to be quiet and shy and try to disappear because they think that if they say something, others will say it is wrong. They are reluctant to talk about themselves for fear of ridicule or humiliation. They fear that they will blush or cry when criticized.
Patients with avoidant personality disorder are very reluctant to take personal risks or participate in new activities for similar reasons. In these cases, they tend to exaggerate the dangers and use minimal symptoms or other problems to explain their elusive side. They may prefer a limited lifestyle because of their need for security and certainty.
Diagnosis of avoidant personality disorder
• Clinical criteria (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5])
For the diagnosis of avoidant personality disorder, patients must have
• Persistent pattern of avoiding social contact, feeling inadequate, and being hypersensitive to criticism and rejection
This pattern is characterized by the presence of ≥ 4 of the following:
• Avoidance of work-related activities that involve interpersonal contact because they fear they will be criticized or rejected or that people will disapprove of them
• Unwillingness to engage with people unless they are sure they are loved
• Reserve in intimate relationships because they fear ridicule or humiliation
• Worry about being criticized or rejected in social situations
• Inhibition in new social situations because they feel inadequate
• Self-assessment as socially incompetent, unpleasant, or inferior to others
• Reluctance to take personal risks or participate in any new activity because they might be embarrassed
In addition, symptoms must have occurred in early adulthood.
Differential diagnosis
Avoidant personality disorder must be distinguished from the following 2 disorders:
• Social Phobia: The differences between social phobia and avoidant personality disorder are subtle. Avoidant personality disorder involves more generalized anxiety and avoidance than social phobia, which is often specific to situations that can result in public embarrassment (eg, public speaking, acting on stage). But social phobia can involve a broader pattern of avoidance and thus can be difficult to distinguish. The 2 disorders often occur together.
• Schizoid personality disorder: both disorders are characterized by social isolation. However, patients with schizoid personality disorder isolate themselves because they have no interest in others, while those with avoidant personality disorder isolate themselves because they are hypersensitive to possible rejection or criticism from others.
Other personality disorders may be similar in some ways to avoidant personality disorder but may be distinguished by characteristic features (e.g., a need to be careful in dependent versus avoidant personality disorder and criticism in personality disorder dodge).
Treatment of avoidant personality disorder
• Cognitive-behavioral therapy focused on social skills
• Supportive psychotherapy
• Psychodynamic psychotherapy
• Anxiolytics and antidepressants
The general treatment of avoidant personality disorder is similar to that for all personality disorders.
Patients with avoidant personality disorder often avoid treatment.
Effective therapies for patients with both social phobia and avoidant personality disorder include
• Cognitive-behavioral therapy that focuses on the acquisition of social skills, done in groups
• Other group therapies if the group is made up of people with the same difficulties
Patients with avoidant personality disorder benefit from
• Individual therapies that are sympathetic and sensitive to the patient's hypersensitivity towards others
Psychodynamic psychotherapy, which focuses on underlying conflicts, can be helpful.
Effective drug treatment includes selective serotonin reuptake inhibitors (SSRIs); anxiolytics, which help reduce anxiety enough to allow patients to expose themselves to new social situations; and monoamine oxidase inhibitors (MAOIs).
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