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Millon & Davis (1996, pp. 253-256) call AvPD the withdrawn pattern.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
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.
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,
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