Perhaps you’ve encountered individuals who seem to really struggle in social situations. They lack confidence in themselves, feel inadequate in social situations and rarely risk getting close to anyone, unless there is absolute certainty they will be liked. They avoid social situations and any type of interaction they believe will be uncomfortable or risky. These behaviors may be signs of a psychiatric condition called avoidant personality disorder (AVPD). AVPD is a serious condition estimated to affect 1.8% to 6.4% of the general population, with incidences of the disorder fairly equally split among men and women.1, 2 Among adults receiving outpatient psychiatry treatment, the incidence is an estimated 3.6% .2
Clinical Diagnostic Criteria
A confirmed diagnosis of AVPD requires that an individual exhibit four of the following seven behaviors:
- Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval or rejection
- Unwilling to get involved with people unless there is certainty of being liked
- Shows restraint within intimate relationships because of the fear of being shamed or ridiculed
- Preoccupied with being criticized or rejected in social situations
- Inhibited in new interpersonal situations because of feelings of inadequacy
- Views self as socially inept, personally unappealing or inferior to others
- Unusually reluctant to take personal risks or to engage in any new activities because they may cause embarrassment
Repercussions of AVPD
AVPD, like all personality disorders, leads to a lifelong pattern of unhealthy behaviors. These patterns and a highly negative self-perception cause problems not only for individuals with the disorder, but also for those around them. Individuals with AVPD may isolate themselves and lack a support network as a result. If they manage to have relationships, they can be overly critical as a defense mechanism and end up alienating and isolating a friend or spouse. They desire affection and acceptance and may fantasize about idealized relationships with others. These behaviors can also adversely affect work situations because interactions that may be required for the basic demands of the job or for career advancement are avoided.3
No one knows exactly why someone develops a personality disorder. The following may be contributing factors not only for AVPD, but also for other personality disorders and phobias.4
Genetic factors: A twin study on Norwegian young adults indicated inheritability of 27% to 35% for AVDP. An estimated 83% of these genes are also linked to other personality disorders.5
Environmental factors: Personality deficits develop largely due to a failure to learn appropriate coping skills while growing up. Avoidant individuals do not learn how to navigate social challenges in a way that benefits them or anyone with whom they interact. As a result, they continually rely on unhealthy coping mechanisms learned early in life.
Child neglect: Retrospective studies on adults with AVDP have reported that 61% of these individuals suffered from emotional abuse in the form of neglect as children. Researchers concluded that childhood neglect is a risk factor for AVPD and may be a defining factor that delineates AVDP from social phobia.6
When personality disordered individuals end up in treatment, it is often because a friend, significant other, family member or employer suggested it out of frustration. Personality disorders, by their very nature, are challenging to treat. Avoidant individuals rarely seek treatment because therapy is essentially a “social” interaction that requires some degree of vulnerability in order to be effective. Vulnerability is something individuals with this disorder pull out all the stops to avoid. The very notion of talking to a therapist about deeply private and personal things is repugnant to individuals with this disorder.
While psychotherapy is the best approach, the caveat is that the therapist needs to specialize in personality disorders due to the aforementioned challenges. Otherwise, both the therapist and the client will likely end up frustrated and therapy will be terminated before any progress is made. A key aspect of psychotherapy, especially for AVPD, is to establish trust and develop a solid therapeutic relationship. The initial goals of therapy are to help individuals gain insight into what drives their maladaptive behavior and how it negatively impacts them as well as other people in their lives. The next step is to help individuals learn more effective social skills and behaviors, ones that allow a healthier, more appropriate manner of interacting with the world around them.
Medication is generally not prescribed for individuals with AVPD because it is ineffective. However, if the individual exhibits symptoms of anxiety, depression, or another co-occurring disorder, medication may be considered.
Co-Occurring and Similar Disorders
Like other personality disorders, it is the norm rather than the exception for AVPD to coexist with other disorders. A 1995 study found that both panic disorder and social phobia were eight to nine times more likely to occur in people with AVPD. The Collaborative Longitudinal Study of Personality Disorder, published in 2000, indicated incidence rates of co-occurring disorders with AVPD, from most frequent to least:
- Major depressive disorder (81.5%)
- Social phobia (38%)
- Depression (30%)
- Post-traumatic stress disorder (28%)
- Obsessive-compulsive disorder (23%)
- Panic disorder (23%)
- Dysthymic disorder (22%)
- Generalized anxiety disorder (22%)
- Borderline personality disorder (17%)
In addition, 45% of the patients in this study met the criteria for alcohol abuse or dependence, and 32% for other substance abuse or dependence.7
Although treatment for AVDP often has limited effectiveness, psychotherapy is worth pursuing. Furthermore, given the high rates of co-occurring disorders, it is likely that other mental health disorders coexist untreated, raising the overall risk of serious repercussions beyond those of AVDP alone. Some people make enough progress in therapy to enable them to make changes in their lives that clearly benefit them and those around them. If the behaviors described above sound familiar, you or a loved one may have undiagnosed AVDP. Do not hesitate to reach out for professional help.
- Avoidant Personality Disorder (AVPD). Out of the Fog website. http://outofthefog.website/personality-disorders-1/2015/12/6/avoidant-personality-disorder-avpd Accessed June 11, 2016.
- Avoidant Personality Disorder. Medscape website. http://emedicine.medscape.com/article/913360-overview#a6 Updated Oct. 7, 2015. Accessed June 11, 2016.
- Avoidant Personality Disorder Symptoms. Psych Central website. http://psychcentral.com/disorders/avoidant-personality-disorder-symptoms/ Updated April 10, 2015. Accessed June 11, 2016.
- Avoidant Personality Disorder Clinical Presentation. Medscape website. http://emedicine.medscape.com/article/913360-clinical Updated Oct. 7, 2015. Accessed June 11, 2016.
- Reichborn-Kjennerud T, Czajkowski N, Neale MC, et al. Genetic and environmental influences on dimensional representations of DSM-IV cluster C personality disorders: a population-based multivariate twin study. Psychol Med. 2007 May. 37(5):645-53.
- Eikenaes I, Egeland J, Hummelen B, Wilberg T. Avoidant Personality Disorder versus Social Phobia: The Significance of Childhood Neglect. PLoS ONE 2015 10(5): e0128737. doi: 10.1371/journal.pone.0128737.
- Sanislow CA, da Cruz K, Gianoli MO, Reagan ER. The Oxford Handbook for Personality Disorders. New York: Oxford University Press; 2012:549-565.