What is avoidant personality disorder?
People with avoidant personality disorder (APD) have a lifelong pattern of extreme shyness. They also feel inadequate and are hypersensitive to rejection. APD can cause psychiatric symptoms that create serious problems with relationships and work.
If you have APD, you might have difficulty interacting in social and work settings. This is because you may fear any of the following:
- rejection
- disapproval
- embarrassment
- criticism
- getting to know new people
- intimate relationships
- ridicule
You may also have trouble believing that people like you. When you’re sensitive to rejection and criticism, you may misinterpret neutral comments or actions as negative ones.
The cause of APD and other personality disorders is unknown. Researchers think genetic and environmental factors might play a role.
There is no way to know who will develop APD. People who have the disorder are typically very shy as children. However, not every child who is shy goes on to develop the disorder. Likewise, not every adult who is shy has the disorder.
If you have APD, your shyness most likely grew as you got older. It may have gotten to the point that you began avoiding other people and certain situations.
Your doctor may refer you to a mental health professional who will ask you questions to determine if you have APD. To be diagnosed with APD, your symptoms must begin no later than early adulthood.
You must also show at least four of the following characteristics:
- You avoid work activities that involve contact with others. This is due to fear of criticism, disapproval, or rejection.
- You’re unwilling to get involved with other people unless you’re sure they like you.
- You hold back in relationships because you’re afraid you’ll be ridiculed or humiliated.
- The fear of being criticized or rejected in social situations dominates your thoughts.
- You hold back or completely avoid social situations because you feel inadequate.
- You think you’re inferior to others, unappealing, and inept.
- You’re unlikely to take part in new activities or to take personal risks because you’re afraid of embarrassment.
Psychotherapy is the most effective treatment for APD. Your therapist may use psychodynamic psychotherapy or cognitive behavioral therapy. The goal of therapy is to help you identify your unconscious beliefs about yourself and how others see you. It also aims to help you function better socially and at work.
Psychodynamic psychotherapy
Psychodynamic therapy is a form of talk therapy. It helps you become aware of your unconscious thoughts. It can help you understand how past experiences influence your current behavior. This allows you to examine and resolve past emotional pains and conflicts. Then you can move forward with a healthier outlook about yourself and how others see you. Psychodynamic psychotherapy produces lasting results with benefits that continue after treatment.
Cognitive behavioral therapy
Cognitive behavioral therapy (CBT) is another form of talk therapy. In CBT, a therapist helps you recognize and replace unhealthy beliefs and thought processes. Your therapist will encourage you to examine and test your thoughts and beliefs to see if they have a factual basis. They’ll also help you develop alternative, healthier thoughts.
Medication
The FDA hasn’t approved any medications to treat personality disorders. However, your doctor may prescribe antidepressant medications if you have co-occurring depression or anxiety.
People who don’t receive treatment for APD may isolate themselves. As a result, they may develop an additional psychiatric disorder, such as:
- depression
- agoraphobia
- substance abuse problems
Treatment doesn’t change your personality. You’ll most likely always be shy and have some difficulty with social and work interactions. But treatment can improve your symptoms and help you develop the ability to relate to others.
Avoidant personality disorder is characterized by the avoidance of social situations or interactions that involve risk of rejection, criticism, or humiliation. Diagnosis is by clinical criteria. Treatment is with psychotherapy, anxiolytics, and antidepressants. People with avoidant personality disorder have intense
feelings of inadequacy and cope maladaptively by avoiding any situations in which they may be evaluated negatively. Reported prevalence of avoidant personality disorder in the US varies, but estimated prevalence is about 2.4%. Avoidant personality disorder affects women and men equally. Comorbidities are common. Patients often also have
major depressive disorder
Major depression (unipolar disorder) Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown... read more , persistent depressive disorder,
obsessive-compulsive disorder
Obsessive-Compulsive Disorder (OCD) Obsessive-compulsive disorder (OCD) is characterized by recurrent, persistent, unwanted, and intrusive thoughts, urges, or images (obsessions) and/or by repetitive behaviors or mental acts that... read more , or an
anxiety disorder
Overview of Anxiety Disorders Everyone periodically experiences fear and anxiety. Fear is an emotional, physical, and behavioral response to an immediately recognizable external threat (eg, an intruder, a car spinning on... read more (eg,
panic disorder
Panic Attacks and Panic Disorder A panic attack is the sudden onset of a discrete, brief period of intense discomfort, anxiety, or fear accompanied by somatic and/or cognitive symptoms. Panic disorder is occurrence of repeated... read more , particularly
social phobia
Social Phobia Social phobia is fear of and anxiety about being exposed to certain social or performance situations. These situations are avoided or endured with substantial anxiety. Phobias are a type of... read more [social anxiety disorder]). They may also have another personality disorder (eg,
dependent
Dependent Personality Disorder (DPD) Dependent personality disorder is characterized by a pervasive, excessive need to be taken care of, leading to submissiveness and clinging behaviors. Diagnosis is by clinical criteria. Treatment... read more ,
borderline
Borderline Personality Disorder (BPD) Borderline personality disorder is characterized by a pervasive pattern of instability and hypersensitivity in interpersonal relationships, instability in self-image, extreme mood fluctuations... read more ). Patients with social phobia and avoidant
personality disorder have more severe symptoms and disability than those with either disorder alone. Research suggests that experiences of rejection and marginalization during childhood and innate traits of social anxiousness and avoidance may contribute to avoidant personality disorder. Avoidance in social situations has been detected as early as about age 2 years. Patients with avoidant personality disorder avoid social interaction, including those at work, because they fear that they will be criticized or rejected or that people will disapprove of them, as in the following situations: They may refuse a promotion because they fear coworkers will criticize them. They may avoid meetings. They avoid making new friends unless they are sure they will be liked. Symptoms and Signs of AVPD
These patients assume people will be critical and disapproving until rigorous tests proving the contrary are passed. Thus, before joining a group and forming a close relationship, patients with this disorder require repeated assurances of support and uncritical acceptance.
Patients with avoidant personality disorder long for social interaction but fear placing their well-being in the hands of others. Because these patients limit their interactions with people, they tend to be relatively isolated and do not have a social network that could help them when they need it.
These patients are very sensitive to anything slightly critical, disapproving, or mocking because they constantly think about being criticized or rejected by others. They are vigilant for any sign of a negative response to them. Their tense, anxious appearance may elicit mockery or teasing, thus seeming to confirm their self-doubts.
Low self-esteem and a sense of inadequacy inhibit these patients in social situations, especially new ones. Interactions with new people are inhibited because patients think of themselves as socially inept, unappealing, and inferior to others. They tend to be quiet and timid and try to disappear because they tend to think that if they say anything, others will say it is wrong. They are reluctant to talk about themselves lest they be mocked or humiliated. They worry they will blush or cry when they are criticized.
Patients with avoidant personality disorder are very reluctant to take personal risks or participate in new activities for similar reasons. In such cases, they tend to exaggerate the dangers and use minimal symptoms or other problems to explain their avoidance. They may prefer a limited lifestyle because of their need for security and certainty.
Clinical criteria (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5])
For a diagnosis of avoidant personality disorder, patients must have
A persistent pattern of avoiding social contact, feeling inadequate, and being hypersensitive to criticism and rejection
This pattern is shown by the presence of ≥ 4 of the following:
Avoidance of job-related activities that involve interpersonal contact because they fear that they will be criticized or rejected or that people will disapprove of them
Unwillingness to get involved with people unless they are sure of being liked
Reserve in close relationships because they fear ridicule or humiliation
Preoccupation with being criticized or rejected in social situations
Inhibition in new social situations because they feel inadequate
Self-assessment as socially incompetent, unappealing, or inferior to others
Reluctance to take personal risks or participate in any new activity because they may be embarrassed
Also, symptoms must have begun by early adulthood.
Avoidant personality disorder must be distinguished from the following 2 disorders:
Cognitive-behavioral therapy focused on social skills
Supportive psychotherapy
Psychodynamic psychotherapy
Anxiolytics and antidepressants
Patients with avoidant personality disorder often avoid treatment.
Effective therapies for patients with both social phobia and avoidant personality disorder include
Cognitive-behavioral therapy that focuses on acquisition of social skills, done in groups
Other group therapies if the group consists of people with the same difficulties
Patients with avoidant personality disorder benefit from
Individual therapies that are supportive and sensitive to the patient's hypersensitivities toward others
Psychodynamic psychotherapy, which focuses on underlying conflicts, may be helpful.
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