Avoidant Personality Disorder
Avoidant Personality Disorder
Avoidant personality disorder is characterized by hypersensitivity to rejection and criticism, desire for uncritical acceptance by others, social withdrawal despite a desire for affection and acceptance, and low self-esteem. The behavior patterns associated with avoidant personality disorder are persistent and severe, impairing the ability to work with others or maintain social relationships.
People who are diagnosed with avoidant personality disorder desire to be in relationships with others but lack the skills and confidence that are necessary in social interactions. In order to protect themselves from anticipated criticism or ridicule, they withdraw from other people. This avoidance of interaction tends to isolate them from meaningful relationships, and serves to reinforce their nervousness and awkwardness in social situations.
The behavior of people with avoidant personality disorder is characterized by social withdrawal, shyness, distrustfulness, and emotional distance. These people tend to be very cautious when they speak, and they convey a general impression of awkwardness in their manner. Most are highly self-conscious and self-critical about their problems relating to others.
Avoidant personalities can be categorized into four types:
- Shy/social phobic avoidants: Use withdrawal mechanisms to manage social anxiety. Shy avoidants have difficulty forming relationships with others and may be seriously isolated. Social phobic avoidants frequently are more symbolic in their withdrawal, and tend to express their avoidance particularly in situations where they are asked to perform in public. Shy/social phobic avoidants are usually perceived as self-conscious or introverted by others.
- “Mingles” avoidants: Appear to be “normal” and well-related in most situations. Although they can form new relationships, they find it difficult to sustain them over time for a variety of reasons including fear of success, desire to fail, and inability to settle down.
- “Seven year itch” avoidants: Although this type is able to form relationships, they are unable to maintain them over time. They may be able to commit fully at first, but become restless over time and leave the relationship.
- Dependent/codependent avoidants: This type of avoidant appears to want to start new relationships but are unable to sever ties to old relationships (e.g., living with one’s parents) that are necessary to make that possible.
The cause of avoidant personality disorder is not clearly defined, and may be influenced by a combination of social, genetic, and biological factors. Avoidant personality traits typically appear in childhood, with signs of excessive shyness and fear when the child confronts new people and situations. These characteristics are also developmentally appropriate emotions for children, however, and do not necessarily mean that a pattern of avoidant personality disorder will continue into adulthood. When shyness, unfounded fear of rejection, hypersensitivity to criticism, and a pattern of social avoidance persist and intensify through adolescence and young adulthood, a diagnosis of avoidant personality disorder is often indicated.
Many persons diagnosed with avoidant personality disorder have had painful early experiences of chronic parental criticism and rejection. The need to bond with the rejecting parents makes the avoidant person hungry for relationships but their longing gradually develops into a defensive shell of self-protection against repeated parental criticisms. Ridicule or rejection by peers further reinforces the young person’s pattern of social withdrawal and contributes to their fear of social contact.
The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, (the fourth edition, text revision or DSM-IV-TR) specifies seven diagnostic criteria for avoidant personality disorder:
- The person avoids occupational activities that require significant interpersonal contact. Job interviews or promotions may be turned down because the person’s own perceptions of his or her abilities do not match the job description.
- The person is reluctant to participate in social involvement without clear assurance that he or she will be accepted. People with this disorder assume other people are not safe to trust until proven otherwise. Others must offer repeated support and encouragement in order to persuade them to participate in a social event.
- The person fears being shamed or ridiculed in close relationships. As a result, people with this disorder become overly alert to behavioral cues that may indicate disapproval or rejection. They will flee a situation in which they believe that others might turn against them.
- The person is preoccupied with being criticized or rejected. Much mental and physical energy is spent brooding about and avoiding situations perceived as “dangerous.”
- The person is inhibited in unfamiliar social situations due to feelings of inadequacy. Low self-esteem undermines his or her confidence in meeting and conversing with new acquaintances.
- The person regards him- or herself as socially inept. This self-disparagement is especially apparent when the person must make social contacts with strangers. People with avoidant personality disorder perceive themselves as unappealing or inferior to others.
- The person is reluctant to take social risks, in order to avoid possible humiliation. Avoidant people seek interactions that promise the greatest amount of acceptance while minimizing the likelihood of embarrassment or rejection. They might go to a school dance, for example, but remain in one corner chatting with close friends rather than going out on the dance floor with someone they do not know well.
Avoidant personality disorder appears to be as frequent in males as in females. It affects between 0.5%and 1.0%of adults in the general North American population, but it has been diagnosed in approximately 10%of clinical outpatients.
Many individuals exhibit some avoidant behaviors at one point or another in their lives. Occasional feelings of self-doubt and fear in new and unfamiliar social or personal relationships are not unusual, nor are they unhealthy, as these situations may trigger feelings of inadequacy and the wish to hide from social contact in even the most self-confident individuals. An example would be the anxious hesitancy of a new immigrant in a country with a different language and strange customs. Avoidant characteristics are regarded as meeting the diagnostic criteria for a personality disorder only when: they begin to have a long-term negative impact on the affected person; they lead to functional impairment by significantly altering occupational choice or lifestyle, or otherwise impinging on quality of life; and cause significant emotional distress.
Avoidant personality disorder can occur in conjunction with other social phobias, mood and anxiety disorders, and personality disorders. The diagnosis may be complicated by the fact that avoidant personality disorder may be either the cause or result of other mood and anxiety disorders. For example, individuals who have major depressive disorder may begin to withdraw from social situations and experience feelings of worthlessness, symptoms that are also prominent features of avoidant personality disorder. On the other hand, the insecurity and isolation that are symptoms of avoidant personality disorder can trigger feelings of depression.
The characteristics of avoidant personality disorder may resemble those found in both schizoid and schizotypal personality disorders. Persons with these disorders are prone to social isolation. Those diagnosed with avoidant personality disorder, however, differ from those with schizoid or schizotypal disorder, because they want to have relationships with others but are prevented by their social inadequacies. Persons diagnosed with schizoid and schizotypal personality disorders, on the other hand, usually prefer social isolation.
Personality disorders are usually diagnosed following a complete medical history and an interview with the patient. Although there are no laboratory tests for personality disorders, the doctor may give the patient a physical examination to rule out the possibility that a general medical condition is affecting the patient’s behavior. For example, people with disorders of the digestive tract may avoid social occasions for fear of a sudden attack of diarrhea or the need to vomit. If the interview with the patient suggests a diagnosis of avoidant personality disorder, the doctor may administer a diagnostic questionnaire or another type of assessment tool.
Assessment tools helpful in diagnosing avoidant personality disorder include:
- Minnesota Multiphasic Personality Inventory (MMPI)
- Millon Clinical Multiaxial Inventory (MCMI)
- Rorschach Psychodiagnostic Test
- Thematic Apperception Test (TAT)
In diagnosis, it is important to distinguish between the fear of relating that characterizes avoidant personality disorder from the inability to form relationships that characterizes schizoid patients. Similarly, it is important to distinguish between the fear of relationship characteristic of the avoidant personality and a healthy, natural desire to be alone.
The general goal of treatment in avoidant personality disorder is improvement of self-esteem and confidence. As the patient’s self-confidence and social skills improve, he or she will become more resilient to potential or real criticism by others.
Psychodynamically oriented therapies
These approaches are usually supportive; the therapist empathizes with the patient’s strong sense of shame and inadequacy in order to create a relationship of trust. Therapy usually moves slowly at first because persons with avoidant personality disorder are mistrustful of others. Treatment that probes into their emotional state too quickly may result in more protective withdrawal by the patient. As trust is established and the patient feels safer discussing details of his or her situation, he or she may be able to draw important connections between their deeply felt sense of shame and their behavior in social situations.
Cognitive-behavioral therapy (CBT) may be helpful in treating individuals with avoidant personality disorder. This approach assumes that faulty thinking patterns underlie the personality disorder, and therefore focuses on changing distorted cognitive patterns by examining the validity of the assumptions behind them. If a patient feels he is inferior to his peers, unlikable, and socially unacceptable, a cognitive therapist would test the reality of these assumptions by asking the patient to name friends and family who enjoy his company, or to describe past social encounters that were fulfilling to him. By showing the patient that others value his company and that social situations can be enjoyable, the irrationality of his social fears and insecurities are exposed. This process is known as “cognitive restructuring.”
Group therapy may provide patients with avoidant personality disorder with social experiences that expose them to feedback from others in a safe, controlled environment. They may, however, be reluctant to enter group therapy due to their fear of social rejection. An empathetic environment in the group setting can help each member overcome his or her social anxieties. Social skills training can also be incorporated into group therapy to enhance social awareness and feedback.
Cognitive restructuring —An approach to psychotherapy that focuses on helping patients examine distorted patterns of perception and thought in order to change their emotional responses to people and situations.
Monoamine oxidase inhibitors (MAOIs) —A group of antidepressant drugs that decreases the activity of monoamine oxidase, a neurotransmitter found in the brain that affects mood. MAOIs are also used in the treatment of avoidant personality disorder.
Supportive —An approach to psychotherapy that seeks to encourage the patient or offer emotional support to him or her, as distinct from insight-oriented or educational approaches to treatment.
Family and marital therapy
Family or couple therapy can be helpful for a patient who wants to break out of a family pattern that reinforces the avoidant behavior. The focus of marital therapy would include attempting to break the cycle of rejection, criticism or ridicule that typically characterizes most avoidant marriages. Other strategies include helping the couple to develop constructive ways of relating to one another without shame.
The use of monoamine oxidase inhibitors (MAOIs) has proven useful in helping patients with avoidant personality disorder to control symptoms of social unease and experience initial success. The major drawback of these medications is limitations on the patient’s diet. People taking MAOIs must avoid foods containing a substance known as tyramine, which is found in most cheeses, liver, red wines, sherry, vermouth, beans with broad pods, soy sauce, sauerkraut, and meat extracts.
Higher-functioning persons with avoidant personality disorder can generally be expected to improve their social awareness and improve their social skills to some degree. But because of the significant social fear and deep-seated feelings of inferiority, these patterns usually do not change dramatically. Lower-functioning persons are likely to drop out of treatment if they become too anxious.
Since avoidant personality disorder usually originates in the patient’s family of origin, the only known preventive measure is a nurturing, emotionally stimulating, and expressive family environment.
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American Psychiatric Association. 1400 K Street NW, Washington DC 20005. <http://www.psych.org>.
Gary Gilles, MA
Paula Ford-Martin, MA
Ruth A. Wienclaw, PhD