AVOIDANT PERSONALITY DISORDER (APD)
For a number of years there was little
distinction between the avoidant personality disorder and the schizoid or
dependent personality disorders. However with the modifications included in
DSM-IV, the three are now sufficiently differentiated.
Essentially, avoidant patients long for close interpersonal relationships, but fear humiliation, rejection, and
embarrassment, and so avoid and distance themselves from others. Schizoid
patients have little need or desire for close interpersonal relationships, and
so avoid and distance themselves from others. Dependent patients are clinging
and submissive because of their excessive need for attachment.
Essentially then, avoidant patients withdraw
because of fears of humiliation, embarrassment, and rejection.
This disorder has a relatively low prevalence
in the general population (estimated to be between .5 and 1 per cent. In
clinical settings, the disorder has been noted in 10 per cent of outpatients.
The reason for this discrepancy is that the presence of a personality disorder
increases the likelihood (to some degree) of suffering from other psychiatric
problems (particularly with APD, depression and anxiety).
Avoidant Personality Disorder can be
recognized by the following behavioral and interpersonal style, thinking or
cognitive style, and emotional or affective style.
Social withdrawal, shyness, distrustfulness,
and aloofness characterize Avoidant patients behavioral style. Their behavior
and speech are controlled, and they appear to be apprehensive and awkward.
Interpersonally, they are sensitive to rejection. Even though they strongly
desire closeness to others, they keep their distance and require unconditional
approval before they are willing to "open up" to others. They tend to
"test" others to see who can be trusted to like them.
The cognitive style of avoidants can be
described as perceptually vigilant. This means that they scan the environment
for clues to potential threats or acceptance. Their thoughts are often
distracted by their hypersensitivity. They have low self-esteem because of their
devaluation of their accomplishments and the overemphasis of their shortcomings.
Their affective or emotional style is marked
by a shy and apprehensive quality. Because unconditional acceptance is
relatively rare, they routinely experience sadness, loneliness, and tenseness.
When more distressed, they will describe feelings of emptiness and
It should be noted that many more people have
avoidant styles as opposed to having the personality disorder. The major
difference has to do with how seriously an individual's functioning in everyday
life is affected. The avoidant personality can be thought of as spanning a
continuum from healthy to pathological. The avoidant style is at the healthy
end, while the avoidant personality disorder lies at the unhealthy end.
DSM-IV Criteria for Avoidant
Personality Disorder (301.82)*
A pervasive pattern of social inhibition,
feelings of inadequacy, and hypersensitivity to negative evaluation, beginning
by early adulthood and present in a variety of contexts, as indicated by four
(or more) of the following:
- avoids occupational activities that involve
significant interpersonal contact, because of fears of criticism,
disapproval, or rejection
- is unwilling to get involved with people
unless certain of being liked
- shows restraint within intimate
relationships because of the fear of being shamed or ridiculed
- is preoccupied with being criticized or
rejected in social settings
- is inhibited in new interpersonal
situations because of feelings of inadequacy
- views self as socially inept, personally
unappealing, or inferior to others
- is unusually reluctant to take personal
risks or to engage in any new activities because they might prove
Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV). American
Social Phobia, Generalized Type; Panic Disorder With Agoraphobia; Dependent Personality Disorder; Schizoid
Personality Disorder; Schizotypal Personality Disorder; Paranoid Personality
Disorder; Personality Change Due to a General Medical Condition; symptoms that
may develop in association with chronic substance use.
The most common syndromes seen with APD
include agoraphobia, social phobia (some clinicians see APD as possibly a
generalized form of social phobia), generalized anxiety disorder, dysthymia (an
emotion of depression), major depressive disorder (the syndrome with all the
associated signs and symptoms), hypochondriasis, conversion disorder,
dissociative disorder, and schizophrenia.
It is now believed that avoidant personality
disorder patients are excellent candidates for treatment (as opposed to some of
the other personality disorders - this is probably due to the healthy desire and
longing for close relationships). Various psychotherapeutic approaches can be
successful, depending on the patients goals, preferences, and psychological
mindedness, and the clinician's expertise.
Generally, the goal of therapy is to increase
the patients self-esteem and confidence in relationship to others, and to
desensitize the individual to the criticism of others. One must beware of the
clinician that is overprotective of the patient and holds up progress - this
sustains the poor view of self that the patient has come to treatment to remedy.
The other clinician to beware is the one who forces the patient to face new
situations prematurely, without proper preparation, and who then criticizes the
patient for not being "brave" enough.
Until fairly recently, most publications spoke
only of psychotherapeutic interventions, and only a few spoke of pharmacological
treatments. Some of the problem is that many patients fear medications and their
side effects just as they do any other new experience. Nevertheless, recent data
indicates that some aspects of extreme social anxiety may be highly drug
responsive. Since APD overlaps greatly with generalized social phobia (which is
very responsive to MAOIs - a type of antidepressant). There are many documented
cases of the successful treatment of APD with MAOIs (such as Parnate, Marplan,
and Nardil). The use of Nardil (phenelzine) often shows improvement in specific
fears and in confidence and assertiveness in social settings. The best
medication intervention should be accompanied by psychotherapeutic methods
appropriate to the individual patient. Medications alone will not give the kind
of lasting improvement that combined treatment can provide. It is important to
remember that medications are not always indicated in every case and that other
considerations (such as general physical health, dietary restrictions, etc)
matter in determining the need for, and possible efficacy, of medications.
Psychotherapy alone works best with the higher functioning APDs, but combined
treatment (psychotherapy and medications) seems to provide the best results for
moderate and more severely disordered patients.