Avoidant Personality Disorder


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Medical Description
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Cluster C:
The Avoidant Personality Disorder (AvPD)
Essential Feature
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Millon & Davis (1996, pp. 253-256) call AvPD the withdrawn pattern.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 

AvPD Behavior
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.

Affective Issues
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).

Defensive Structure
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, 
pp. 43-44).

Medication Issues
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 
Psychiatric Association.



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