DSM-IV-TR criteria

A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety o contexts, as indicated by four (or more) of the following:

1. avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection
2. is unwilling to get involved with people unless certain of being liked
3. shows restraint within intimate relationships because of the fear of being shamed or ridiculed
4. is preoccupied with being criticized or rejected in social situations
5. is inhibited in new interpersonal situations because of feelings of inadequacy
6. views self as socially inept, personally unappealing, or inferior to others
7. is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing

Associated features

• People with Avoidant Personality Disorder often appraise every movement and expression of those whom they are around. They can be fearful and tense which can elicit the ridicule of others which confirm preconceived self-doubts. They tend to be very anxious thinking that they will react to criticism with crying or blushing. Others describe them as “shy,” “lonely,” “timid,” and “isolated.” Their major problems are in social and occupational functioning. Their low self-esteem and hypersensitivity to rejection can restrict interpersonal contacts. Individuals may become isolated and do not usually have a large social support network to help them. They want affection and acceptance and fantasize over idealized relationships. The avoidance behaviors also adversely affect occupational functioning because of the fear the individuals have of social situations. They may try to avoid situations that are important for jobs and advancements.
• These individuals are fearful of the possibility of criticism, rejection, or disapproval and therefore, will usually not engage in social relationships unless they are assured of being liked. However, these individuals desire affection and thus are often lonely and bored. They may even go to the extreme where they avoid work situations that involve a lot of interpersonal situations and contacts. Being alone is not enjoyed and is caused by their inability to relate to others, which causes extreme anxiety and often leads to low self-esteem and being excessively self-conscious. Ridicule and rejection are seen when in fact none exists. Also, they also tend to say or do little when they have to be involved in social situations because they are fearful that they will say something silly or foolish. They see themselves as being incompetent, inferior to other people, and are not risk takers. They generally do not get involved in or with new activities.
• Co-morbidity is often displayed with Dependent Personality Disorder. This occurs because when a friend or friends are made, they become extremely attached to and dependent on that individual. Avoidant personality disorder is also co-morbid with Borderline PD and the Cluster A disorders, Paranoid, Schizoid, and Schizotypal. It is often diagnosed with Mood and Anxiety Disorders, especially generalized Social Phobia and unipolar depression.

Child vs. Adult Presentation

• Avoidant Personality Disorder does not typically become a diagnosis of children. The normal guideline is that usually no one under the age of 18 are diagnosed with this disorder. Most patients, however, report that their symptoms were present during childhood or adolescents.

Gender and Cultural Differences in Presentation

• There may be variations in the prevalence of diagnosed individuals across cultures as the degree of appropriate diffidence and avoidance differs between societies. Avoidant behavior may also be influenced by problems in acculturation following immigration (“culture shock”). Avoidant Personality Disorder seems to occur equally between males and females.

Epidemiology

• Prevalence rates of Avoidant Personality Disorder for the general population are between 0.5% and 1%. There is a prevalence rate between 2% and 5% in the general population, and around 15% in psychiatric outpatient settings. It is reported that about 10% of outpatients seen in mental health clinics also have Avoidant Personality Disorder.
• Avoidant behavior often starts in infancy. Shyness is normal in children, but tends to dissipate with age. Those who develop Avoidant Personality Disorder may become increasingly shy over time. Some evidence suggests that APD tends to lesson or remit with age.

Etiology

• There is evidence to suggest that genetic factors play a role in the development of Avoidant PD. Shyness is also believed to be genetically inherited or linked to a person. There is a link to bio-genetic tendencies toward a lowered autonomic arousal threshold.
• Environmental factors also play a role in a person with Avoidant PD. A history of being ridiculed or rejection may cause the person to later develop this disorder.
• May have parental or peer rejection and/or ridicule.
• Recent studies show evidence of shyness in post birth temperaments (compared to children the same age).

Empirically Supported Treatments

• A mixture of medication to reduce sensitivity when being rejected and cognitive therapy seems to work best for people with Avoidant PD compared to medication alone or therapy alone.
• Treatment can be vital to living anything close to a “normal” life. Without treatment, those who suffer from APD make retreat completely to their homes. They will begin to avoid every and any social event instead of just most. They might also develop a second disorder along with their APD that could have been completely avoided altogether.

Psychodynamically oriented therapies

• According to the Encyclopedia of Mental Disorders 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 a more protective withdrawal by the patient. As trust is established and the patient feels safer discussing details of his or her situations, 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.

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.

Medications

• 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.

Prevention

• 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.
• Read more: www.encyclopediaofmentaldisorders.com

Avoidant PD versus Social Phobia

• Avoidant PDs were less socially skilled than those with social phobia
• There were differences on behavioral skill factors, molecular behaviors such as eye contact, and on overall skill
• Looking at psychophysiological and cognitive variables, there are no differences between the two
• APD reported:
  • more social avoidance and subjective distress
  • significantly higher score on the SCL-90-R Interpersonal Sensitivity scale as well as on the SCL-90-R Anxiety, Depression, and Obsessive-Compulsive subscales. (Turner, Beidel, Dancu, & Keys, 1986)

Portrayed in Popular Culture

• Rubeus Hagrid from Harry Potter
  • Although he develops strong relationships with several characters in the series, his half-giant background and shameful exits from Hogwarts make him very sensitive to the opinions of others

DSM-V Changes

• Reformulated as the Avoidant Type
• Individuals who match this personality disorder type have a negative sense of self, associated with a profound sense of inadequacy, and inhibition in establishing intimate interpersonal relationships.
• More specifically, they feel anxious, inadequate, inferior, socially inept, and personally unappealing; are easily ashamed or embarrassed; and are self-critical, often setting unrealistically high standards for themselves.
• At the same time, they may have a desire to be recognized by others as special and unique.
• Avoidant individuals are shy or reserved in social situations, avoid social and occupational situations because of fear of embarrassment or humiliation, and seek out situations that do not include other people.
• They are preoccupied with and very sensitive to being criticized or rejected by others and are reluctant to disclose personal information for fear of disapproval or rejection.
• They appear to lack basic interpersonal skills, resulting in few close friendships. Intimate relationships are avoided because of a general fear of attachments and intimacy, including sexual intimacy.
• Individuals resembling this type tend to blame themselves or feel responsible for bad things that happen, and to find little or no pleasure, satisfaction, or enjoyment in life’s activities.
• They also tend to be emotionally inhibited or constricted and have difficulty allowing themselves to acknowledge or express their wishes, emotions – both positive and negative – and impulses.
• Despite high standards, affected individuals may be passive and unassertive about pursuing personal goals or achieving successes, sometimes leading to aspirations or achievements below their potential.
• They are often risk averse in new situations

(APA, 2010)