Avoidant Personality Disorder DSM-5 301.82 (F60.6)
DSM-5 Category: Personality Disorder
Avoidant personality disorder (APD) is an enduring pattern of feelings of inadequacy, hypersensitivity to being negatively evaluated by others, and extreme shyness that begins by early adulthood and endures over time, is inflexible and present in a variety of situations, differs from an individual’s cultural norms, and results in significant distress or impairment in occupational, social, or other areas of functioning. People with APD generally desire social connection, but are crippled by a sense of personal inadequacy and intense fears of social rejection (Sanislow, Bartolini, and Zoloth, 2012).
Individuals with ADP tend to have had experiences that serve to deflate their self-esteem through degradation, humiliation, or rejection. With repeated negative experience they develop a view of themself as being unlikable and defective and of others as being uncaring and likely to reject them. Some researchers have maintained that ADP is a more severe and generalized form of social phobia (Heimberg, 1996; Herbert, Hope, & Bellak, 1992).
The DSM-5 reports that APD affects approximately 2.4 percent of the population (American Psychiatric Association, 2013). Among patients in outpatient psychiatric clinics, there is between 10% and 20% of that population affected by APD.
Symptoms of Avoidant Personality Disorder
Although the disorder was described in the early 1900’s, the term “Avoidant Personality Disorder” was not used until DSM-III in 1980. In the DSM-5, APD is included in the “Cluster C” personality disorders, along with Dependent Personality Disorder and Obsessive-Compulsive Personality Disorder. These disorders share common features of anxiety, fearfulness, and the internalization of distress. In the case of APD, the person suffers from deep feelings of inadequacy and sensitivity to rejection that they tend to choose isolation rather than risk the pain of being negatively evaluated (Rettew, 2013).
Rogge and Kirkland (2014) list seven criteria for Avoidant Personality Disorder. The person must exhibit at least four to meet the diagnostic threshold. The criteria are:
- Avoids occupational activities involving significant interpersonal contact, due to fears of criticism, disapproval, or rejection
- Is unwilling to get involved with people unless certain of acceptance
- Shows restraint within intimate relationships due to fears of shame or ridicule
- Preoccupied with fears of receiving criticism or rejection in social situations
- Inhibited in new interpersonal situations due to feelings of inadequacy
- Considers self as inferior to others, socially inept, or personally unappealing
- Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing
The first criterion, “avoids occupational activities involving significant interpersonal contact, due to fears of criticism, disapproval, or rejection,” applies to work or school environments (Sanislow et al., 2012). Because of this, the DSM-5 asserts that persons suffering from APD tend to limit their educational opportunities. In addition, they are likely to choose professions where interpersonal contact is minimal. Further, they avoid working in groups or teams, preferring to complete projects independently.
The second criterion, “is unwilling to get involved with people unless certain of acceptance,” often manifests by the refusal to initiate social contact or join groups. People with APD assume that other people will be disapproving and critical and avoid social interaction unless there are clear signals of acceptance and approval.
The third criterion, “shows restraint within intimate relationships due to fears of shame or ridicule,” is driven by the fear of being criticized. Individuals with APD believe that if they were truly known by others, they would be almost certainly be disliked and rejected (Sanislow et al., 2012), which they experience as excruciating.
The fourth criterion, “preoccupied with criticism or rejection in social situations,” highlights the extreme sensitivity of individuals with ADP. Even the slightest tease could be perceived as ridicule. As a result, APD is frequently associated with a great deal of secretive behaviour that is, for the most part, irrational, except for the fact that it brings a needed security even in their “closest” relationships (American Psychiatric Association, 2013).
The fifth criterion, '”inhibited in new interpersonal situations due to fears of inadequacy,” involves more than mere cautiousness. It often involves social comparisons that may have no real basis; for example that others whom the avoidant is with are smarter, more attractive, and more successful. As a result of their extreme cautiousness, people suffering with ADP tend to withhold information about themselves that could actually lead to the experience of being like and respected by others. However, their extremely negative self-evaluation and defensive inhibition prevents others from knowing them well enough for that to occur.
The sixth criterion, “views self as inferior to others, socially inept, or personally unappealing,” focuses on the person’s negative view about themselves. Because of insecurities about their worth and competencies, individuals with APD anticipate that others will judge or otherwise evaluate them negatively (Sanislow et al., 2012). While negative self perception is also present in many depressive disorders and in social anxiety disorder, in APD these feelings of ineptness and being unlikeable start no later than early adulthood, are independent are independent of mood, and are pervasive.
The seventh criterion, “is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing,” refers to the individual’s defensive efforts to avoid being painful negative. People diagnosed with ADP take this to the extreme. They do not start conversations, reveal information, or call attention to themselves. Even the most mundane and pedestrian social interactions feel overwhelmingly risky. Exposing emotions, whether positive or negative, is unbearably vulnerable. If a person with APD has a thought or feeling, they would be likely to wait for another person to share the thought or feeling and then agree with that person rather than risk what to them would be certain humiliation that would accompany making a “stupid” disclosure that was “off the mark” (Sanislow et al., 2012).
Treatment of Avoidant Personality Disorder
The U. S. National Library of Medicine states that psychotherapy is the most effective means for treating persons diagnosed with ADP. Psychotherapy works by helping the individual with this disorder become less sensitive to rejection (Penn Medicine's Health Encyclopedia, 2014).
Psychotherapy for ADP typically includes a variety of elements (Sanislow, et al., 2012). Because the people with ADP tend to view themselves in such a negative light, to anticipate rejection from others, and to believe that rejection will be unbearable, they often never seek treatment because they expect that their therapist will dislike them.
When they do seek treatment, therapists must be particularly mindful to avoid behaving in a manner that could be interpreted as judgmental or disapproving. Because the person with APD is sensitive to even mild criticism, the APD patients might perceive the therapist as critical even if there were no real basis for that perception. In addition, ADP patients have a tendency to question the authenticity of their therapist's concern, resulting in an increased risk of terminating treatment prematurely.
Providing genuine empathy and emotional warmth is essential to build trust that is foundational for effective treatment. After successfully establishing trust, the therapeutic relationship provides a context for exploring and reconsidering negative beliefs about oneself, the likelihood of being negatively evaluated by others, and one’s ability to tolerate the pain and other consequences associated with feeling criticized. Therapists help patients to identify the beliefs about themselves and the risks associated with interacting with others and to modify them. Therapists also help patients to develop social skills, initially in the relationship with the therapist, which can function as a place to learn and practice how to interact with others. Once skills are acquired, patients gradually expose themselves to social situations to increase their confidence and learn that the reality is far less intimidating than what they had imagined.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Heimberg, R. G. (1996). Social phobia, avoidant personality disorder and the multiaxial conceptualization of interpersonal anxiety. In P. M. Salkovskis (Ed.), Trends in cognitive and behavioural therapies (pp. 43-61). London: Wiley.
Herbert, J.D., Hope, D. A., & Bellack, A. S. (1992). Validity of the distinction between generalized social phobia and avoidant personality disorder. Journal of Abnormal Psychology, 101, 332-339.
Rettew, D. C., Pataki, C., Jellinek, M. S., Doyle, A. C., Windle, M. L., & Sylvester, C. (2013). Avoidant personality disorder. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001936/
Rogge, T., & Kirkland, W. A. (2014). Avoidant personality disorder. The New York Times. Retrieved from http://www.nytimes.com/health/guides/disease/avoidant-personality-disorder/overview.html
Sanislow, C. A., Bartolini, E. E., & Zoloth, E. C. (2012). Avoidant personality disorder. In V. S. Ramachandran (Ed.), Encyclopedia of Human Behavior, 2nd Ed. (pp. 257-266). Academic Press: San Diego.
Sanislow, C. A., Little, T. D., Ansell, E. B., Grilo, C. M., Daversa, M., Markowitz, J. C.,… McGlashan, T. H. (2009). Ten-year stability and latent structure of the DSM-IV schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders. Journal of Abnormal Psychology 118: 507-519.
IV schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders. Journal of Abnormal Psychology 118: 507-519.
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