Avoidant personality disorder

What is avoidant personality disorder?

People with avoidant personality disorder experience significant social difficulties. These issues go well beyond simply being shy or introverted. Rather, social inhibition and avoidance reduces the ability to maintain healthy relationships at work and in one’s personal life.

Some of the symptoms of avoidant personality disorder include:

• Fear of rejection or criticism
• Low self-esteem and feelings of inadequacy
• Little social involvement or complete avoidance of social situations
• Preoccupation with signs of disapproval
• Self-isolation
• Social anxiety
• Anxiety or extreme nervousness surrounding intimacy

This disorder is persistent, with symptoms presenting in various social situations. Symptoms tend to appear in early adulthood and can sometimes be accompanied with anxiety disorders, however research suggests anxiety disorders and avoidant personality disorder are not two separate disorders, rather two different lenses looking at the same issue.^[1] 

Types of avoidant personality disorder

The DSM-V doesn’t specify different types of avoidant personality disorder. However, Theodore Millon, a psychologist whose work was crucial for APD becoming part of the DSM-III,^[8] posited that there are four subtypes. Millon suggested that each type typically appears in adulthood and has different presenting features:^[1]

• Phobic avoidant, which involves maladaptive fears of specific objects or situations. This type also includes features of a dependent personality, such as clinginess and passivity. 
• Conflicted avoidant, which includes unresolvable feelings of anxiety or dread. Also present are features of passive-aggressive behavior, such as crankiness and argumentativeness.
• Hypersensitive avoidant, which features feelings of suspicion and panic. People with this type of disorder might be thin-skinned and present paranoid features, including hypersensitivity to perceived threats.
• Self-deserting avoidant, which involves the abandonment of self-awareness. Depressive features are often present as well, including persistent feelings of agitation and despair. Suicidal ideation is also common with this subtype.

APD is widely misunderstood and often misdiagnosed - problems that were even more significant before Millon’s work. Though not incorporated into the DSM-V, it might be easier to identify and understand the symptomology of APD through this lens.

Symptoms of avoidant personality disorder

Avoidant personality disorder symptoms can manifest in a variety of ways. Multiple symptoms and are often present simultaneously. Common symptoms include social isolation, feelings of worthlessness, and anxiety.^[3]

Social isolation, and a pattern of avoidance leads to significant isolation from others and a lack of participation in enjoyable events. This might include:

• A lack of close interpersonal relationships
• A lack of romantic relationships
• Avoidance of social functions
• Unwillingness to try new things

For example, someone with avoidant personality disorder may rarely go out with family or friends out of fear that strangers will judge them. Instead, social interactions might only occur in safe spaces, such as at home. This can lead to patterns of agoraphobia.

Feelings of worthlessness, in which a person with this disorder feels incompetent, unworthy, and presents as fearful or tense. This might include:

• Low self-esteem
• Feelings of inferiority
• Feelings of shame

For example, people with this disorder have feelings of worthlessness that can be so intense that forming new relationships is extremely difficult unless there are guarantees that others will like them.

Anxiety, in which there is an intense fear of saying or doing the wrong thing, along with a lack of trust in others. This might include:

• Social anxiety
• Social phobia
• Social inhibition
• Hypervigilance for signs of disapproval

For example, people with this disorder have pervasive thoughts of negative reactions from others. As such, they tend to be timid and quiet in social situations to minimize the chances of being criticized.

It’s worth noting that avoidant personality disorder symptoms can occur on a continuum, with some symptoms being severe and others being less severe. In some cases, people might present as having high functioning avoidant personality disorder because their symptoms do not appear to be crippling. However, this is often a misinterpretation of their experience.

Diagnosing avoidant personality disorder

The first step in diagnosing avoidant personality disorder is to see a mental health professional, who will assess your current level of functioning through a series of questions and observations about your behavior.

Mental health professionals rely on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, or DSM-V, to provide structure to the diagnostic process. The DSM-V offers the following criteria for diagnosing avoidant personality disorder.^[15]

• Avoid work activities requiring significant social contact due to fears of rejection, criticism, or disapproval.
• Unwillingness to engage in social interactions unless there is a guarantee of being liked.
• Lack of intimate relationships for fear of ridicule or rejection.
• A preoccupation with rejection or criticism.
• Feelings of inadequacy lead to inhibited social interactions in new interpersonal settings.
• A pervasive feeling of social ineptitude and inferiority to others, as well as feeling personally unappealing.
• Lack of new activities, particularly personal risks, for fear of embarrassment.

Diagnosis depends on four or more of the above criteria being present in various contexts (thus the reason that high functioning avoidant personality disorder is not a clinical diagnosis).

Causes of avoidant personality disorder

The cause of avoidant personality disorder is not known at this time. However, like many mental health issues, there are likely many causes^[17], including:

• Environmental factors, such as emotional abuse
• Genetic factors
• Social factors, including ridicule by others
• Psychological factors, such as extreme shyness as a child

Other risk factors include rejection from peers, lack of affection from loved ones, and the presence of a related mental health condition, such as an anxiety disorder.

Prevention of avoidant personality disorder

There is no known prevention for avoidant personality disorder. However, an early evaluation is critical to treat the disorder effectively. If you have any of the symptoms or risk factors listed above, consult a mental health professional for an assessment.

Treatment for avoidant personality disorder

There are two primary avoidant personality disorder treatment approaches - therapy and medication.

Therapies include:

• Psychodynamic therapy, which explores the unconscious mind and past painful memories, thoughts, and feelings.^[14]
• Cognitive-behavioral therapy (CBT), which seeks to reveal negative thoughts, change thinking patterns, and teach positive coping strategies.^[14]
• Schema therapy, which focuses on the relationship between the client and therapist as a means of learning ways to improve daily functioning while also developing an understanding of past experiences.^[16]

There are currently no approved medications specifically for avoidant personality disorder treatment. However, medications like anxiolytics or antidepressants can address some of the symptoms associated with this disorder. Drug treatments combined with therapy have been shown in research to produce the best results.^[6]

Self-care for avoidant personality disorder

Significant risks of avoidant personality disorder include extreme social isolation, depression, and substance abuse, if the disorder goes untreated. Being proactive regarding self-care, and pursuing appropriate treatment, can help lessen symptoms.

Self-care should focus on basic strategies such as:

• Avoiding the use of alcohol or drugs
• Making healthy life choices (e.g., getting plenty of rest and exercise, eating healthy foods, and spending time outdoors)
• Identifying safety behaviors that bring about calm when feelings of anxiety occur (e.g., listening to music)
• Using enjoyable activities as a vehicle for safe social interactions (e.g., if you enjoy pottery, consider taking a pottery class with a friend or family member)

Additionally, therapy can provide the support and encouragement you need to develop and carry out a self-care plan, while medications can help reduce symptoms.

Helping someone with avoidant personality disorder

If you know someone with avoidant personality disorder, there are many avenues you can take to support them in coping and thriving.^[2]

• Encourage them to attend therapy
• Be available to assist with treatments
• Appropriately express your feelings and emotions as a means of modeling that behavior.
• Be available to provide support in social situations, as appropriate.
• Be encouraging, offer positive affirmations, and provide validation when appropriate.

It’s important to be patient, too. Wholesale change is not going to occur. Instead, be available for a long journey of baby steps that lead to improved functioning.

Conditions relating to avoidant personality disorder

Avoidant personality disorder can occur with other personality disorders, anxiety disorders, and substance abuse disorders, to name a few.^[6] This might include:

• Other personality disorders, such as dependent personality disorder^[11]
• Depressive disorders, such as persistent depressive disorder^[12]
• Anxiety disorders, such as social anxiety disorder^[13]
• Specific phobias, such as agoraphobia^[9]
• Substance-related and addictive disorders, such as alcohol use disorder^[10]

FAQs about avoidant personality disorder

What is the outlook for people with avoidant personality disorder?

Without treatment, people with this disorder can become completely isolated, depressed, and dependent upon substances to cope.^[7] Likewise, other conditions might present themselves, like those listed in the previous section.

However, treatment can help improve the symptoms associated with this disorder. The outlook is even better if treatment occurs early and with support, such as from a friend or family member. 

Avoidant Personality Disorder vs Social Anxiety – What is the difference?

These disorders are highly similar, and some clinicians believe they exist on a continuum, with avoidant personality disorder being a severe form of social anxiety.^[8] That notwithstanding, there are some significant differences between the two.

First, avoidant personality disorder involves avoiding virtually all types of social interaction. By contrast, social anxiety might manifest only in certain situations (e.g., public speaking).

Second, people with social anxiety recognize that their anxiety is maladaptive. People with avoidant personality disorder might not have the same level of recognition.^[5]

A third difference is that these disorders might have different causes. While childhood experiences might be a factor in the development of both disorders, avoidant personality disorder seems to be associated with a greater level of childhood neglect or abuse.^[4]

For more information on this, read our article on the difference between social anxiety disorder and avoidant personality disorder.

How common is avoidant personality disorder?

This disorder affects about 1.5-2.5 percent of the general population.^[5] It appears to be slightly more common in women than in men.