The Avoidant Personality Disorder (AvPD)
The essential feature of the avoidant personality disorder is a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation (DSM-IV, 1994, p. 662).
The ICD-10 (1994, p. 232) has a personality disorder called the anxious (avoidant) personality disorder characterized by feelings of tension, apprehension, insecurity and inferiority. These individuals wish to be liked and accepted but experience hypersensitivity to rejection and criticism. Personal attachments are restricted. People with the anxious personality disorder have a tendency to avoid activities by a habitual exaggeration of the potential dangers or risks involved. They believe that they are socially inept, personally unappealing and inferior.
Millon & Davis (1996, pp. 253-256) call AvPD the withdrawn pattern. These are individuals who are oversensitive to social stimuli and are hyperreactive to the moods and feelings of others. Individuals with AvPD are chronically overreactive and hyperalert, with affective disharmony, cognitive interference, and interpersonal distrust. They are disposed toward the more severe schizophrenic disorders. Historically, this pattern has been described as being preoccupied with security and strained in associating with people.
Everly (Retzlaff, ed., 1995, pp. 25-38) states that the most severe pathology found in AvPD is in the area of self-image. In AvPD there is the failure of the core personality to adapt in a competent manner to interpersonal adversity -- presumably both past and present. Stone (1993, p. 355) also sees the key traits of AvPD as social reticence and avoidance of interpersonal activities. These individuals are easily hurt by criticism and fear showing their anxiety in public. They would like to be close to others and to live up to their potential, but are afraid of being hurt, rejected, and unsuccessful (Beck, 1990, p. 43).
There is overlap between AvPD and social phobia, generalized type (DSM-IV, 1994, pp. 663-664). The essential feature of social phobia (social anxiety disorder) is a marked and persistent fear of social or performance situations that may provoke embarrassment. Most often, the social or performance situation is avoided though it may be endured with dread. The avoidance, fear or anxious anticipation must interfere significantly with daily routine, occupational functioning, or social life or cause significant personal distress (DSM-IV, 1994, p. 411). Sutherland & Frances (Gabbard & Atkinson, eds., 1996, p. 991) suggest that AvPD and social phobia are constructs that differ only in the severity of dysfunction. Frances, et.al. (1995, p. 376) propose the possibility that they are two different constructs for the same condition. Benjamin (1993, p. 294) notes that the interpersonal patterns for generalized social phobia are very similar to AvPD; both groups avoid social contact and restrain themselves because of fear of humiliation or rejection. She proposes that social phobia is diagnosed if symptoms of pervasive anxiety or panic are present. Millon and Martinez (Livesley, ed., 1995, p. 222) believe that the avoidant personality is essentially a problem of relating to people while social phobia is largely a problem of performing in situations. Stone (1993, pp. 355-356) suggests that social phobia, agoraphobia, and OCD often have an underlying AvPD.
It is common for persons with AvPD to have comorbidity with other personality disorders. AvPD is most often diagnosed with DPD, BPD, PPD, SPD, or StPD (DSM-IV, 1994, p. 663). Frances, et.al (1995, p. 376) note the considerable overlap between AvPD and DPD. These two personality disorders share interpersonal insecurity, low self-esteem, and a strong desire for interpersonal relationships. Benjamin (1993, p.301) describes the desperate attempts to avoid being alone that may be seen in DPD as an exclusionary indicator for AvPD.
AvPD is found equally in males and females (DSM-IV, 1994, p. 663).
Individuals with AvPD are preoccupied by the unpleasant and perplexing personal definition they hold of themselves as defective, unable to fit in with others, being unlikable, and being inadequate. This self-image usually results from childhood rejection by significant others such as parents, siblings, or peers. These individuals then believe that others throughout their lives will react to them in a similar fashion. They are often unable to recognize their own admirable qualities that make them both likable and desirable (Will, Retzlaff, ed., 1995, p. 97). Rather, they see themselves as socially inept and inferior. They believe that they are personally unappealing and interpersonally inadequate. They describe themselves as ill at ease, anxious, and sad. They are lonely; they feel unwanted and isolated. Individuals with AvPD are introspective and self-conscious. They usually refer to themselves with contempt (Millon & Davis, 1996, p. 263).
For individuals with AvPD, their deflated self-image references their entire being. Nothing about them escapes their own self-derision (Millon & Davis, 1996, p. 264). Doubts about their social competence and personal appeal become especially severe in the presence of strangers (DSM-IV, 1994, p. 662).
View of Others
Individuals with AvPD view the world as unfriendly, cold, and humiliating (Millon & Davis, 1996, p, 265). People are seen as potentially critical, uninterested, and demeaning (Beck, 1990, pp. 43-44); they will probably cause shame and embarrassment for individuals with AvPD. As a result, people with AvPD experience social pananxiety and are awkward and uncomfortable with people (Millon & Davis, 1996, p. 261). However, they are caught in an intense approach-avoidance conflict; they believe that close relationships would be rewarding but are so anxious around people that their only solace or comfort comes in avoiding most interpersonal contact (Donat, Retzlaff, ed., 1995, p. 49).
Individuals with AvPD tend to respond to low-level criticism with intense hurt. To make matters worse, they become so socially apprehensive that neutral events may well be interpreted as evidence of disdain or ridicule by others (Donat, Retzlaff, ed., 1995, p. 49). They come to expect that attention from others will be degrading or rejecting. They assume that no matter what they say or do, others will find fault with them (DSM-IV, 1994, p. 662).
Even memories for individuals with AvPD are comprised of intense, conflict-ridden, problematic early relationships. They must avoid the wounds inside of them at the same time they are avoiding the external distress of contact with others. The external environment brings no peace and comfort and their painful thoughts do not allow them to find solace within themselves (Millon & Davis, 1996, pp. 263-264).
Individuals with AvPD are "lonely loners." They would like to be involved in relationships but cannot tolerate the feelings they get around other people. They feel unacceptable, incapable of being loved, and unable to change. Because they retreat from others in anticipation of rejection, they lead socially impoverished lives. They have immature and unrealistic expectations of relationships; they believe that they can have no imperfections if they are to be accepted and loved. Interpersonally, they are ill at ease, awkward and tense. They experience unremitting self-consciousness, self-contempt and anger toward others (Oldham, 1990, pp. 188-193).
Individuals with AvPD will develop intimacy with people who are experienced as safe. Nevertheless, they will often engage in triangular marital or quasi-marital relationships which provide intimacy while maintaining interpersonal distance. These individuals like to foster secret liaisons as a "fall-back" position in case the key relationship does not work out (Benjamin, 1983, pp. 307-308). As sexual partners and parents, people with AvPD appear self-involved and uncaring (Kantor, 1992, p. 109) as they preserve distance from others through defensive restraint and withdrawal. Even so, these individuals long for affection and fantasize about idealized relationships (DSM-IV, 1994, p. 663).
Issues With Authority
Individuals with AvPD are unlikely to provoke or resist authority. At least at a behavioral level, they are inclined to be compliant and cooperative. However, whether the authority figures are service providers or law enforcement officers, people with AvPD are not forthcoming and resist self-disclosure. Exposure means, for these individuals, ridicule, shame, and censure. They will not willingly give away the information that they believe will result in such painful experiences.
Individuals with AvPD behave in a fretful, restive manner. They overreact to innocuous experiences but maintain control over their physical behaviors and expression of emotions. Their speech is hesitant and constrained. They appear to have fragmented thought sequences and their conversation is laced with confused digressions. They are timid and uneasy (Millon & Davis, 1996, p. 261).
Kantor (1992, pp. 36-41) notes that individuals with AvPD, as with all of the personality disorders, have a tendency to live in the past or in fantasy -- they receive too little input from the here and now. This diminished ability to pay attention results in mild memory disturbances and a characteristic immaturity. These individuals are distracted by their own extraordinary sensitivity to subtleties of tone and feeling; they are hyperalert to the meaning of emotive communication. Their thought processes are interfered with by flooding of irrelevant environmental details (Millon & Davis, 1996, p. 263).
Individuals with AvPD behave in a stiff, shy, and apprehensive manner that is disquieting to others. The very rejection they fear may be the direct result of other people becoming impatient and uncomfortable with their unremitting tension and inability to accept that they can be a part of interaction without special guarantees of safety. In fact, people with AvPD, overtly or covertly, are seeking others to take the interpersonal risks for them; they are not able to be responsible for their own well-being socially and become a burden on the nurturing and care-taking capacity of those around them. For those who experience severe avoidant symptoms, no amount of protectiveness or gentleness can ease their fear; they will withdraw without explanation and leave behind a general bewilderment about what went wrong.
Shame is one of the central AvPD affective experiences. Shame and self-exposure are intimately connected -- which leads to withdrawal from interpersonal connection to avoid experiencing shame (Sutherland & Frances, Gabbard & Atkinson, eds, 1996, p. 993). These individuals are anguished. They describe their emotions as a constant and confusing undercurrent of tension, sadness, and anger. Sometimes this relentless pain results in a general state of numbness. They posses few social skills and personal attributes that can lead them to the pleasures and comforts of life. They must attempt to avoid pain, to need nothing, to depend on no one, and to deny desire. They try to turn away from their awareness of their unlovability and unattractiveness (Millon & Davis, 1996, p. 265).
Feeling capacity is normal for individuals with AvPD; it is their affective expression that is limited. Insight is present but superficial and not useful; it is seldom used for change (Kantor, 1992, p. 108). Their main affect is dysphoria, a combination of anxiety and sadness (Beck, 1990, p. 44). They are apprehensive, lonely, and tense (Sperry & Carlson, 1993, p. 332); they can experience feelings of emptiness, depersonalization (Sperry, 1995, p. 36), and excessive self-consciousness. Occasionally, individuals with AvPD lose control and explode with rage (Benjamin, 1983, p. 297).
Individuals with AvPD utilize fantasy to interrupt their painful thoughts. They seek to muddle their emotions because diffuse disharmony is more tolerable than the sharp pain and anguish of being themselves. They also depend on fantasy for some measure of need gratification. Other AvPD defenses include avoidance and escape. Their paramount goal is to protect themselves from real or imagined psychic pain. Fantasy and escape are all that is left because they cannot gain comfort from themselves or from others (Millon & Davis, 1996, pp. 264-265).
Dorr (Retzlaff, ed., 1995, p. 196) also notes that individuals with AvPD can deal with their emotions only through avoidance, escape, and fantasy. When faced with unanticipated stress, they have few internal strengths available to them to manage the situation. Energy is misdirected to avoid rather than to adapt. While these individuals seek isolation out of fear of humiliation or rejection, they desire relationships and connection. That leaves them with fantasy as their primary defense; here, the use of fantasy can be seen as a variant of the general defense of denial (Kubacki & Smith, Retzlaff, ed., 1995, p. 167).
Individuals with AvPD take rejection as an indication of personal deficiencies; they engage in a string of automatic self-critical thoughts that are extraordinarily painful. The resultant AvPD social avoidance is readily apparent. What is less obvious is the concurrent cognitive and emotional avoidance. Their dysphoria is so painful that they use activities and addictions to distract them from negative thoughts and feelings as well. They engage in wishful thinking, e.g. one day the perfect relationship or job will come along; one day they will be confident and have many friends. The patterns of cognitive, emotional, and behavioral avoidance are reinforced by a reduction in sadness and become ingrained and automatic (Beck, 1990, pp. 257-265). Meanwhile, individuals with AvPD lower their reality-based expectations and stay clear of involvement with real people (Beck & Freeman, 1990, pp. 43-44).
It is recommended, for personality disordered individuals, to medicate target symptoms rather than the personality disorder itself. AvPD is quite vulnerable to the target symptom of dysphoria which is usually accompanied by mood instability, low energy, leaden fatigue, and depression. Also associated with dysphoria is a craving for chocolate and for the use of stimulants, e.g., cocaine. Many dysphoric individuals will respond to standard antidepressant medications (Ellison & Adler, Adler, ed., 1990, p. 53). Global improvement for individuals with AvPD may be possible in response to tranylcypromine, phenelzine, or fluoxetine. (Ellison & Adler, Adler, ed., 1990, p. 47)
Anxiety, defined as an unpleasantly heightened responsivity of the autonomic nervous system to interpersonal and environmental cues may be beneficially medicated with beta blockers, MAOIs, and the triazolobenzodiazepine alprazolam (Ellison & Adler, Adler, ed., 1990, pp. 53-54). While benzodiazepines can be effective for AvPD, the use of these medications should be balanced with the these individuals' propensity for substance dependence. The newer SSRIs may be effective for the core features of AvPD: shyness, rejection sensitivity, heightened psychic pain, and distorted cognition related to self-criticism and self-effacement (Sutherland & Frances, Gabbard & Atkinson eds., 1996, p. 993).
The specific features of personality disorders affect compliance with medication. Individuals with AvPD may be alarmed at the possibility of side effects and react with fear to the medication (Ellison & Adler, Adler, ed., 1990, p. 59) (Sperry, 1995, p. 50).
On the other hand, anti-anxiety medication will be very appealing to individuals with AvPD. It is possible, however, that sedative-hypnotics are the clients' drug of choice and tolerance is already in place. These individuals must develop non-chemical courage and the tolerance they actually need is for interpersonal anxiety. Even if they are not already involved with minor tranquilizers, they are likely to overvalue their effects. Iatrogenic addiction is a significant concern. One psychiatrist in a major community mental health system stated emphatically that it was so painful to be avoidant that he would prefer to allow an addiction to benzodiazepines to develop than to ask these individuals to tolerate their psychological discomfort. While this position may (or may not) be understandable, addiction is not an acceptable alternative to the symptoms of AvPD. Treatment can be effective and non-addicting medications can assist with the symptoms well enough to facilitate the change process.
Information and or Criteria summarized from:
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.
Changed Oct 03, 2001.