Avoidant Personality Disorder (AvPD)

Avoidant Personality Disorder (AvPD)
AVPD Introduction

Avoidant personalty disorder: CRINGES (4 criteria).
C: Certainty (of being liked required before willing to get involved with others)
R: Rejection (or criticism) preoccupies one's thoughts in social situations
I: Intimate relationships (restraint in intimate relationships due to fear of being samed)
N: New interpersonal relationships (is inhibited in)
G: Gets around occupational activity (involing significant interpersonal contact)
E: Embarrassment (potential) prevents new activity or taking personal risks
S: Self viewed as unappealing, inept, or inferior

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 sufficiently differentiated.

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 for attachment.

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 style.

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 following:

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" enough.

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.
Avoidant Personality Disorder (AVPD) is a serious condition which has been found in clinical studies to affect between 1.8% to 6.4% of the general population.
Avoidant Personality Disorder is listed in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) as a "Cluster C" anxious or fearful disorder.
AVPD is characterized by a pattern of withdrawal, self-loathing and heightened sensitivity to criticism. People who suffer from AVPD often consider themselves socially unsuccessful and tend to remove themselves from social situations in order to avoid the feeling or the risk of feeling rejected by others.
People who live in a relationship with a person who suffers from avoidant personality disorder often recognize that something is not quite right with the behavior of their family member or loved-one but often do not know what to do about it or that there is even a name for it. They may feel trapped in the relationship and frustrated by their loved-one's tendency to pull them away from family, friends and other "everyday" social settings.
People who are in a relationship with a person who suffers from AVPD may also experience pressure to isolate themselves along with them or pressure to protect them from criticism or to create an artificial or dysfunctional "bubble" or ideal environment around them in which they can escape the risk of negative self-thought.
People who suffer from AVPD may use withdrawal as a form of communication or as a form of emotional control over friends, partners and family members.

Alternate Names for AVPD
Avoidant Personality Disorder (AvPD) is described in the World Health Organization's International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) by the alternate name Anxious Personality Disorder or Anxious (Avoidant) Personality Disorder.

Characteristics of AVPD
The following is a list of some of the more common characteristics & traits of people who suffer from Avoidant Personality Disorder (AVPD). Click on the links to see more information on each trait.
Note that these traits are given as a guideline only and are not intended for diagnosis. People who suffer from AVPD are all unique and so each person will display a different subset of traits. Also, note that everyone displays "avoidant" behaviors from time to time. Therefore, if a person exhibits one or some of these traits, that does not necessarily qualify them for a diagnosis of AVPD.
"Always" & "Never" Statements - "Always" & "Never" Statements are declarations containing the words "always" or "never". They are commonly used but rarely true.
Avoidance - Avoidance is the practice of withdrawing from relationships with other people as a defensive measure to reduce the risk of rejection, accountability, criticism or exposure.
Blaming - Blaming is the practice of identifying a person or people responsible for creating a problem, rather than identifying ways of dealing with the problem.
Catastrophizing - Catastrophizing is the habit of automatically assuming a "worst case scenario" and inappropriately characterizing minor or moderate problems or issues as catastrophic events.
Circular Conversations - Circular Conversations are arguments which go on almost endlessly, repeating the same patterns with no real resolution.
"Control-Me" Syndrome - "Control-Me" Syndrome describes a tendency that some people have to foster relationships with people who have a controlling narcissistic, antisocial or "acting-out" nature.
Dependency - Dependency is an inappropriate and chronic reliance by an adult individual on another individual for their health, subsistence, decision making or personal and emotional well-being.
Depression - When you feel sadder than you think you should, for longer than you think you should - but still can't seem to break out of it - that's depression. People who suffer from personality disorders are often also diagnosed with depression resulting from mistreatment at the hands of others, low self-worth and the results of their own poor choices.
Emotional Blackmail - Emotional Blackmail describes the use of a system of threats and punishments on a person by someone close to them in an attempt to control their behaviors.
Engulfment - Engulfment is an unhealthy and overwhelming level of attention and dependency on a spouse, partner or family member, which comes from imagining or believing that one exists only within the context of that relationship.
Escape To Fantasy - Escape to Fantasy is sometimes practiced by people who present a facade to friends, partners and family members. Their true identity and feelings are commonly expressed privately in an alternate fantasy world.
False Accusations - False accusations, distortion campaigns & smear campaigns are patterns of unwarranted or exaggerated criticisms which occur when a personality disordered individual tries to feel better about themselves by putting down someone else - usually a family member, spouse, partner, friend or colleague.
Fear of Abandonment - Fear of abandonment is a pattern of irrational thought exhibited by some personality-disordered individuals, which causes them to occasionally think that they are in imminent danger of being rejected, discarded or replaced by someone close to them.
FOG - Fear, Obligation & Guilt - The acronym FOG, for Fear, Obligation and Guilt, was first coined by Susan Forward & Donna Frazier in Emotional Blackmail and describes feelings that a person often has when in a relationship with someone who suffers from a personality disorder. Our website, Out of the FOG, is named after this acronym.
Hoovers & Hoovering - A Hoover is a metaphor, taken from the popular brand of vacuum cleaners, to describe how an abuse victim, trying to assert their own rights by leaving or limiting contact in a dysfunctional relationship gets "sucked back in" when the perpetrator temporarily exhibits improved or desirable behavior.
Hyper Vigilance - Hyper Vigilance is the practice of maintaining an unhealthy level of interest in the behaviors, comments, thoughts and interests of others.
Identity Disturbance - Identity disturbance is a psychological term used to describe a distorted or inconsistent self-view.
Impulsiveness and Impulsivity - Impulsiveness - or Impulsivity - is the tendency to act or speak based on current feelings rather than logical reasoning.
Lack of Object Constancy - A lack of object constancy is a symptom of some personality disorders. Lack of object constancy is the inability to remember that people or objects are consistent, trustworthy and reliable, especially when they are out of your immediate field of vision. Object constancy is a developmental skill which most children do not develop until 2 or 3 years of age.
Learned Helplessness- Learned helplessness is when a person begins to believe that they have no control over a situation, even when they do.
Low-Functioning - A Low-Functioning Personality-Disordered Individual is one who is unable to conceal their dysfunctional behavior from public view or maintain a positive public or professional profile.
Low Self-Esteem - Low Self-Esteem is the common term used to describe a group of negatively-distorted self-views which are inconsistent with reality.
Mirroring - Mirroring is a term which describes imitating or copying another person's characteristics, behaviors or traits.
Mood Swings - Mood swings are unpredictable, rapid, dramatic emotional cycles which cannot be readily explained by changes in external circumstances.
Neglect - Neglect is a passive form of abuse in which the physical or emotional needs of a dependent are disregarded or ignored by the person responsible for them.
Objectification - Objectification is the practice of treating a person or a group of people like an object.
Panic Attacks - Panic Attacks are short intense episodes of fear or anxiety, often accompanied by physical symptoms, such as hyperventilating, shaking, sweating and chills.
Parentification - Parentification is a form of role reversal, in which a child of a personality-disordered parent is inappropriately given the role of meeting the emotional or physical needs of the parent or of the other children.
Passive-Aggressive Behavior - Passive Aggressive behavior is the expression of negative feelings, resentment, and aggression in an unassertive, passive way (such as through procrastination and stubbornness).
Perfectionism - Perfectionism is the practice of holding oneself or others to an unrealistic, unsustainable or unattainable standard of organization, order or accomplishment in one particular area of living, while sometimes neglecting common standards of organization, order or accomplishment in others.
Projection - Projection is the act of attributing one's own feelings or traits onto another person and imagining or believing that the other person has those same feelings or traits.
Sabotage - Sabotage is the spontaneous disruption of calm or status quo in order to serve a personal interest, provoke a conflict or draw attention.
Selective Competence - Selective Competence is the practice of demonstrating different levels of intelligence, resourcefulness, strength or competence depending on the situation or environment.
Selective Memory and Selective Amnesia - Selective Memory and Selective Amnesia is the use of memory, or a lack of memory, which is selective to the point of reinforcing a bias, belief or desired outcome.
Self-Loathing - Self-Loathing is an extreme self-hatred of one's own self, actions or one's ethnic or demographic background.
Self-Victimization - Self-Victimization or "playing the victim" is the act of casting oneself as a victim in order to control others by soliciting a sympathetic response from them or diverting their attention away from abusive behavior.
Splitting - Splitting is a psychological term used to describe the practice of thinking about people and situations in extremes and regarding them as completely "good" or "bad".
Testing - Testing is the practice of repeatedly forcing another individual to demonstrate or prove their love or commitment to the relationship.
Thought Policing - Thought Policing is any process of trying to question, control, or unduly influence another person's thoughts or feelings.
Tunnel Vision - Tunnel Vision is the habit or tendency to only see or focus on a single priority while neglecting or ignoring other important priorities.

DSM-IV-TR Criteria for Avoidant Personality Disorder (AvPD)
Avoidant Personality Disorder (AvPD) is listed in the DSM-IV-TR as a Cluster C (anxious or fearful) Personality Disorder.
Text in Italics is quoted from the American Psychiatric Association’s Diagnostic & Statistical Manual (DSM-IV-TR)
Avoidant Personality Disorder (AvPD) is defined as:
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 following:
  1. Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection.
  2. Is unwilling to get involved with people unless certain of being liked.
  3. Shows restraint initiating intimate relationships because of the fear of being ashamed, ridiculed, or rejected due to severe low self-worth.
  4. Is preoccupied with being criticized or rejected in social situations.
  5. Is inhibited in new interpersonal situations because of feelings of inadequacy.
  6. Views self as socially inept, personally unappealing, or inferior to others
  7. Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.
A formal diagnosis of AvPD requires a mental health professional to identify 4 out of the above 7 criteria as positive. Some people with AvPD may exhibit all 7. Most will exhibit only a few.

Nobody’s perfect. Even normal healthy people will experience or exhibit a few of the above criteria from time to time. This does not make a person AVPD.
Understanding the clinical criteria for Avoidant Personality Disorder (AVPD) is helpful but learning how to cope with having a loved-one who suffers from AVPD is quite different and is not covered in any psychological manual.

AVPD Statistics
Refer to our page on Personality Disorder Statistics for More Information.
Avoidant Personality Disorder has been found in separate clinical studies to affect anywhere from 1.8% to 5.2% of the general population.
People who are diagnosed with Avoidant Personality Disorder also frequently meet the criteria for other personality disorders.
The table below shows statistically how likely it is that a person who is diagnosed with AVPD will also meet the criteria for another personality disorder. The more positive the number, the more likely it is that a person will be diagnosed with the second personality disorder listed. The more negative the number, the less likely it is that a person will be diagnosed with the second personality disorder in the table.
Personality Disorder Comorbidity Odds-Ratio
Paranoid Personality Disorder 0.70
Schizoid Personality Disorder 0.55
Schizotypal Personality Disorder 0.53
Antisocial Personality Disorder 0.05
Borderline Personality Disorder 0.54
Dependent Personality Disorder 0.70
Obsessive-Compulsive Personality Disorder 0.63
UK Hospital Admission Statistics in 2006/2007 show that 43% of those admitted with a diagnosis of AVPD were male and 57% female.

AVPD Treatment & Causes
The precise causes of AVPD are not well understood. Genetic traits and child abuse or neglect are most often associated with the disorder, but no conclusive study exists.
Most people who suffer from Avoidant Personality Disorder are, by nature, reluctant to seek out treatment and programs such as individual therapy, couples therapy and group therapy are likely to make someone with AVPD feel very uncomfortable. As a result, most cases of AVPD go undiagnosed and untreated and it is left to spouses, partners and family members and friends to do the best they can.
For those who have sought treatment, some symptoms of AVPD have been found to be reduced through prescription of SSRI antidepressants. Therapy programs typically involve social skills training, cognitive behavioral therapy and group therapy.

Movies Portraying Avoidant Personality Disorder (AvPD)
The Remains of the Day - The Remains of the Day is a 1993 Columbia Pictures Release, starring Anthony Hopkins & Emma Thompson which portrays the life of a head butler in an English Manor who manifests some of the traits of schizoid personality disorder.
Zelig - Zelig is a 1983 movie written and directed by Woody Allen who portrays a man who avoids revealing his own self by adapting his personality to mirror anyone whom he is interacting with.

AVPD Support Groups & Links:
Out of the FOG Support Forum - Support Forum here at Out of the FOG.
https://www.bigtent.com/groups/avoidant - Active Avoidant Personality Disorder Community
http://www.avoidantpersonality.com - Avoidant Personality Disorder Support Site.

http://groups.msn.com/AvoidantPersonalityG...ssageboard.msnw - MSN Avoidant Personality Group.
Psychforums AVPD forum - Psychforums Site.