Avoidant Personality Disorder AvPD/APD
Avoidant personality disorder (APD) ís considered to be an active-
detached personality pattern, meaning that avoidants purposefully
avoid people due to fears of humiliation & rejection. It ís thought
to be a pathological syndromal extension of the "normal inhibited"
personality, which ís characterized by a watchful behavioral
appearance, shy interpersonal conduct, a preoccupied cognitive style,
uneasy affective expression & a lonely self-perception ( Millon &
Everly ). According to this view, the avoidant pattern seems to range
ín varying degrees along a symptomological continuum from mild to
extreme. In mild cases, a person may be said to be normally shy,
whereas extreme cases indicate personality disorder.
APD vs. Generalized Social Phobia:
The symptoms of APD overlap with those of generalized social phobia.
Widiger (1992) reviewed 3 studies (Holt; Herbert; Turner et al.
[1992]) which demonstrated that GSP & APD are based on the same
underlying pathology & differ primarily ín the severity of social
anxiety & social functioning, with APD being the more severe
disorder. The evidence that most people diagnosed with APD will also
meet the diagnostic criteria for GSP, but people with GSP do not
necessarily have APD supports this view.
DSM Criteria:
The DSM-IV describes APD as:
A pervasive pattern of social inhibition, feelings of inadequacy &
hypersensitivity to negative evaluation, beginning by early adulthood
& present ín a variety of contexts, as indicated by 4 (or more) of
the following:
avoids occupational activities that involve significant interpersonal
contact because of fears of criticism, disapproval or rejection
ís 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
ís preoccupied with being criticized or rejected ín social situations
ís inhibited ín new interpersonal situations because of feelings of
inadequacy views self as socially inept, personally unappealing or
inferior to others
ís unusually reluctant to take personal risks or to engage ín any new
activities because they may prove embarrassing.
How does APD manifest itself?
The usual onset for APD ís early adulthood, with an equal prevalence
rate among women & men (APA). According to one study however,
(Greenberg & Stravynski, 1985) most of the people being referred for
professional help for social dysfunction, considered to be the same
disorder as APD by Marks (1987), were single men. One suggested
hypothesis for this finding ís that society expects men to be the
initiators ín romantic relationships. Therefore, when they do not
form relationships, ít ís seen as more of a problem than women who do
not initiate relationships but are not expected to ín any case
(Marks). Millon & Everly have suggested 6 dimensions onto which the
symptoms of APD can be mapped.
Behavioral Appearance:
Avoidants do exhibit the stereotypical traits of shyness, timidity &
withdrawing behavior. To those who know them well, the avoidants'
mistrust of others may also be apparent as an almost constant
wariness. However, Kantor (1993) argues that behavioral hostility ís
also typical of those suffering with APD. Avoidants may use their
shyness as a way to hurt others by preventing them from becoming
close. Alternatively, they will demonstrate their hostility ín a more
overt manner by insulting people who attempt to be friendly, for
example. This reaction may be because they are identifying their
aggressor & "deal with feared rejection by becoming rejecting
themselves." These expressions of hostility could be seen as
defensive fight responses. To protect themselves from being rejected,
they reject others first. This ís maladaptive because the avoidants
will tend to reject many people who would never have rejected them ín
the first place.
In terms of appearance, íf ít ís affected at all by APD, ít will tend
to be affected ín one of 3 ways. 1st, avoidants may put considerable
time & effort into making themselves attractive to others. The idea
behind this ís, at least they will be liked for their looks, íf not
for themselves. 2nd, they may consciously, or unconsciously, ensure
that their appearance drives others away. This provides them with
some control over their lives. Rather than waiting helplessly to be
rejected, they ensure rejection from the start by their own actions.
3rd, ín the case of avoidants who are suffering from PTSD, for
example, they may dress ín the style of the era when the trauma
occurred. This form of dress ís an indication that they are living ín
the past.
Speech ís may also be affected ín APD. Avoidants may be quite silent.
As Jerome Kagan explains, "For a rabbit, freezing on a lawn ís a sign
of fear. I believe that speechlessness ís a similar diagnostic sign
for us… There's a circuit ín the brain that controls our vocal cords
& becoming quiet can be one sign of fear." (Galvin, 1992). When they
do speak, avoidants may use frequent pauses & speak slowly (Millon &
Everly). This ís contrary to what we read regarding social phobia,
where pauses ín speech tended to be avoided because they were thought
to be a sign of lack of knowledge. Avoidants may also be
overtalkative, possibly due to an adrenic discharge or a false
belief, such as continuously talking will prevent death. For
avoidants who try to put people off with their behavior, insults or
social faux pas are commonly used as a way to assure rejection
(Kantor). While this does essentially realize their worst fear, ít
does again give avoidants some control over how others react to them.
Interpersonal Conduct:
Avoidants often test others to determine whether or not they are
being sincere ín their friendliness. Because they may frequently see
rejection where ít does not exist, people will tend to fail these
tests & then later be avoided because they may reject or humiliate
those with APD (Millon & Everly). They will, therefore, frequently
have difficulty beginning & maintaining relationships (Kantor),
partly because they have difficulty trusting others & thus, are very
reluctant to share their feelings or allow themselves to be
vulnerable. As a protective measure against the humiliation &
rejection, they may become avoidant of others.
On the other hand, avoidants may form relationships, even making an
effort to meet new people. However, these people are kept at a
distance. Therefore, this group of avoidants ís avoiding intimacy,
rather than avoiding people altogether.
Cognitive Style:
Avoidants excessively monitor the situation to the extent that they
are trying to process so much information, they are no longer paying
sufficient attention to the interaction itself (Millon & Everly). The
literature on social phobia suggests that the phobics are unable to
follow the interaction because they are so focussed on their internal
reactions. However, the research on avoidant personality disorder
also emphasizes that the avoidants are engaged ín external monitoring
of the other person's reactions as well. This additional processing
of information could contribute to the increased severity of APD over
social phobia. The excessive monitoring by avoidants, combined with a
hypersensitivity to rejection makes their perception of rejection
almost inevitable.
Their dysfunctional thought processes may also include fear of being
vulnerable, because ít makes ít easier to get hurt or humiliated.
They may also be perfectionists & reject anyone who does not live up
to their impossible standards. This may again be a case of rejecting
someone before they are rejected themselves. Another possibility ís
that they are degrading the other person so that íf they are rejected
they will find ít less painful because they didn't like the person
anyway. Some people believe that relationships are just too much work
& aren't worth the effort. Rationalization may also be present ín
this belief with the idea that ít ís not because they are unable to
form relationships that they don't have any, ít ís that they do not
want to waste their time on relationships. Some avoidants even
believe that they must avoid intimacy because "giving love to others
reduces the energy they have available for themselves & that they
need for their vital life processes," (Kantor).
Affective Expression:
People with APD may exhibit little affect due to the fear that
showing their emotions will make them vulnerable to rejection or
humiliation (Kantor; Millon & Everly). To observers, avoidants may
appear tense & anxious (Millon & Everly).
Avoidants tend to have low self-esteem & believe that they are
unworthy of being ín successful relationships. They are also very
self-conscious, frequently lonely & see their accomplishments as
being of little or no worth (Millon & Everly).
Primary Defense Mechanism:
To cope with their unhappiness, people with APD often escape into
fantasy which ís "a `safe' medium ín which to discharge affection,
aggression or other impulses that would otherwise be inappropriate,
uncomfortable or impossible to achieve ín reality," (Millon &
Everly). Avoidants will tend to read, watch TV or daydream to escape
from reality.
Etiology & Development:
From an evolutionary point of view, the "fight-or-flight" dichotomy
suggests that both hostility & avoidance are naturally occurring
responses to fear. Both are thought to be based on anxiety evoked by
the presence of a feared stimulus object or situation. However,
avoidance can co-vary with fear, vary inversely or vary independently
(Rachman & Hodgson, 1974). Therefore, avoidance behavior seems to be
more complex than ís accountable for by the simple presence of fear
or anxiety. What appear to be purposeful hostile reactions to others,
for example, may be indicative of highly complex psychological
It ís commonly believed that biological factors, including heredity &
prenatal maternal factors, set the foundation for personality &
personality disorders, while environmental factors shape the form of
their expression (Millon & Everly). In the case of avoidant
personality disorder, the evidence of major biogenic influences ín
íts etiology & development ís speculative & weak (Millon & Everly).
However, there ís some evidence that a timid temperament ín infancy
may predispose individuals to developing APD later ín life (Kaplan &
Sadock, 1991). While shyness appears to indicate underactivity, Kagan
believes that this inherited tendency to be shy ís actually the
result of overstimulation or an excess of incoming information. Timid
individuals cannot cope with the excess of information & so withdraw
from the situation as a self-protective measure. The inability to
cope with this information overload may be due to a low autonomic
arousal threshold (Venebles, 1968). The same mechanism may also be
responsible for the avoidant's hypervigilence. However, ít ís
generally believed that these biological substrates exist within the
avoidant personality as a biological foundation for the emergence of
the disorder itself & that full development of APD ís likely due to
significant environmental influences (Millon & Everly).
Environmental Factors
Parental Rejection:
An important environmental factor ín the development of avoidant
personality disorder ís parental rejection (Kantor; Millon & Everly).
Although normal, healthy infants may encounter varying degrees of
parental rejection, the amount of rejection seems to be particularly
intense &/or frequent for people who subsequently develop APD.
Frequent or intense rejections crush children's natural energy &
optimism, leaving instead attitudes of self-deprecation & feelings of
social isolation. Rejection by parents appears to be particularly
devastating because ít may be interpreted as a direct contradiction
to the commonly held edict of unconditional love & acceptance of
offspring by their parents. The rejected child asks, "if my parents
won't accept me, who will?", yet some children learn that their
parents do not accept them, thus the question ís always present &
every person the avoidant interacts with will be put to the test.
Although avoidance ín children does not appear to be necessarily
linked to APD ín adulthood, ít appears that particular kinds of
rejection by parents can alter the attitude & behavior of children ín
a way that disposes them to develop the disorder more easily later ín
life. For example, Kantor suggests that íf a child's expression of
positive emotion ís met with remoteness, criticism or punishment, he
might learn to spare himself anguish by keeping positive feelings to
himself. Perhaps such a child might abandon positive feelings
altogether. There ís little doubt that this would jeopardize later
adult relationships.
Likewise, íf a child's negative feelings are rejected, for example,
íf she ís repeatedly told "it's bad to feel angry", she might forego
otherwise workable relationships ín order to avoid not only the
intermittent feelings of dissatisfaction or anger that are an
inevitable part of practically all close relationships, but also her
ambivalence toward negative feelings ín general.
Furthermore, parental rejection may indicate some underlying parental
fear, which the child unconsciously imitates. In such a case, the
child may learn not only to fear rejection from others, but also to
believe that the world ís a fearful place.
Peer Rejection:
A 2nd environmental factor implicated ín the emergence of APD ís
rejection by peer groups. If a child leaves a hostile or rejecting
situation & encounters positive reinforcing experiences outside of
the home, early rejection by parents need not result ín self-
deprecating attitudes. However, íf parental or familial (including
siblings) rejection ís compounded by rejection from a peer group, the
prognosis points heavily toward a personality disorder.
Repeated social interactions expose an individual to potential
rejection over a sustained period of time. Such rejection, íf ít
occurs, can wear down the individual's sense of self-competence &
self-esteem. Following humiliation & rejection by peers, individuals
then begin to criticize themselves. Feelings of loneliness &
isolation are made worse because of harsh self-judgments & increasing
feelings of personal inferiority & self-worthlessness contribute to
withdrawing behavior. Rejection by their peers seems to validate the
rejection by their parents. When children cannot turn to their
parents, their peers, or even themselves for gratification or
validation, they retreat. Avoidant personality may be the result.
Other Factors:
In addition to rejection by parents & peers, ít ís speculated that
several other factors can play more & less significant roles ín the
development & persistence of APD. For example, children who are
infantalized by their parents may have difficulty relating to people
outside of the family. As adults they may be regressive & dependent
ín relationships. Avoidance may also be recommended by parents,
peers, teachers, entertainers, religious leaders & the media as
protection against the evils of the world. Unresolved rivalry with
siblings has been suspected of inducing transferential jealous
competition among individuals, leading to avoidant behavior. Also,
sexual feelings, for example Freud's (1950) "incest taboo", may
unconsciously lead to avoidance of close relationships with parents &
later with potential partners. It has been noted that sometimes
avoidants isolate themselves ín order to manage strong ambivalent or
negative feelings toward sex (Kantor). In psychopathic proportions,
avoidance may lead to a purposive distancing ín order to enhance
sexual fantasies (Shapiro, 1981). In some cases, a more poignant
expression of sexual disgust may be expressed as love revulsion, a
condition ín which the avoidant has learned to "love" isolation, not
because ít ís a real preference but because ít ís a defense against a
forbidden desire to be with others (Kantor). Finally, transference
can lead to avoidant behavior when an individual distances herself
from people who remind her of something or someone she disliked or
feared ín the past — often parents, but also others outside of the
The Self-perpetuating Cycle of APD:
Avoidants have limited contact with others when they use avoidance to
protect themselves from being rejected. People notice the withdrawing
behavior of the avoidant individual which leads either to a
reciprocal avoidance by the observer or ridicule of the avoidant by
those observing his hermit-like behavior. As Millon & Everly point
out, often people who appear weak or timid attract the attention of
those who enjoy belittling others. A cycle of withdrawal, ridicule or
rejection, further withdrawal & so on, perpetuates the avoidant
personality disorder.
The avoidant ís painfully alert to the minutest signals of rejection
from others. Unfortunately, being hypersensitive to rejection often
lowers avoidants' ability to correctly perceive what ís & what ís not
rejection. They may imagine rejection where none exists or view a
minor & partial rejection as one that ís major & complete. They feel
that every rejection follows from a thoughtful evaluation of their
real worth when they know that people who reject others sometimes do
so because they have problems of their own (act reflexively &
transferentially rather than thoughtfully & realistically) (Kantor).
The strategy they have adopted to protect themselves backfires & the
fears associated with the negative view of themselves seems to be
confirmed. As the pattern repeats itself & the problem magnifies, the
avoidant finds him or herself ín a world of self-fulfilling prophecy.
Furthermore, as avoidants withdraw more & more from social
situations, they are left with an increasing amount of time to
reflect upon their sorrowful state. Like an unrequited love affair,
avoidants' desire for interpersonal relationships peaks & most often
the conclusion they reach ís that they are not only incapable of
improving their attractiveness or likeability to others, but that
they do not even deserve acceptance. This fosters more avoidance &
alienation (Millon & Everly).
Finally, we cannot overlook the importance of operant conditioning ín
the perpetuation of avoidant personality disorder. The avoidant
desires social affiliation yet ís fearful of rejection & humiliation.
The pattern of avoidant, seclusive, aloof & hypersensitive behavior
that characterizes the disorder ís negatively reinforcing to the
individual. That ís, through avoidant behaviors, these individuals
can reduce the probability that they will be rejected or humiliated.
Thus the behavior ís reinforced & the disorder ís made more severe
(Millon & Everly).
Avoidance reduction ís typically an action-oriented approach to
handling the causes, complications & consequences of APD. It borrows
from the active techniques found ín other psychotherapies. For
example, "total push", from behavior therapy, forces avoidants to
face social interactions for longer periods of time; supportive
therapy gives encouragement ("you can do it"), positive feedback
("you are good enough to succeed") & reassurance ("you can handle the
anxiety"); family therapy tries to convince the smothering family to
stop infantilizing the individual; & pharmacological therapy advises
administering anti-depressant medication to help allleviate the
avoidant's anxiety. Generally, avoidants are encouraged to "do"
rather than contemplate, to engage themselves ín fearful situations
as a means of overcoming their fear.
In summary, those with APD are extremely sensitive toward & fearful
of, rejection by others. Their reaction to this fear may be a flight
response, ín the case of avoidance, but may also be a fight response,
ín the case of hostility. While genetics may predispose individuals
to developing this disorder, ít ís thought that the environment or
more specifically, early failed relationships are the pivotal cause
of the development of APD. Through their own dysfunctional thoughts &
behaviors, avoidants inadvertently perpetuate their suffering. Active
behavioral therapies are recommended & sometimes medication ís
Lorri Baier-Barth, Amanda Crawford