"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
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
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
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 depersonalization.
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
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 embarrassing.
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).
American Psychiatric Association
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"
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."