Symptoms and Features of Avoidant Personality Disorder

Avoidant personality disorder (APD) is an enduring pattern of behavior related to social inhibition, feelings of inadequacy, and sensitivity to rejection that causes problems in work situations and relationships. People with the disorder show a pattern of avoidance due to fear of rejection or disapproval, which they experience as extremely painful. The disorder affects about two and one-half percent of the population, with roughly equal numbers of men and women being afflicted.

The following is a list of common symptoms associated with avoidant personality disorder:

• Social inhibition
• Feelings of inadequacy
• Hypersensitivity to negative evaluation
• Anxiety about saying or doing the wrong thing
• A need to be well-liked
• Avoiding situations due to fear of rejection
• Avoiding intimate relationships or sharing intimate feelings
• Avoiding social situations or events
• Avoiding interaction in work settings or turning down promotions
• Avoiding conflict (being a "people-pleaser")
• Low self-esteem
• Lack of assertiveness
• Extreme self-consciousness
• Viewing oneself as socially inept or inferior
• Lack of trust in others
• Self-isolation
• Failure to initiate social contact
• Anhedonia (lack of pleasure in activities)
• Anxiety in social situations
• Avoiding making decisions
• Vigilant for signs of disapproval or rejection
• Easily hurt by criticism or disapproval
• No close friends/lacking a social network
• Unwilling to take risks or try new things
• Fearful and tense demeanor
• Misinterpreting neutral situations as negative

The causes of avoidant personality disorder are thought to involve genetic, environmental, social, and psychological factors. Emotional abuse, criticism, ridicule, or lack of affection or nurturing by a parent may result in the development of this personality disorder if other factors are also present. Rejection by peers may similarly be a risk factor.

Often, individuals with the disorder are very shy as children and do not outgrow this shyness as they age.

Avoidant personality disorder can only be diagnosed by a trained mental health professional based on criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). While a family physician can be the first point of contact for a diagnosis, your doctor should make a referral to a psychologist, psychiatrist, or other professional for diagnosis.

Avoidant personality disorder is typically diagnosed in adults, as children's personalities are still developing, and behaviors such as shyness can be normal experiences in childhood that are later outgrown.

According to the DSM-5, a person must have a consistent pattern of avoiding social contact, being overly sensitive to rejection and criticism, and feeling inadequate, as displayed by at least four of the following criteria:

• Avoidance of occupational activities involving significant social contact out of fear of criticism, disapproval, or rejection
• Unwillingness to become involved with others unless you are certain that they will like you
• Holding back in intimate relationships out of fear of being ridiculed or humiliated
• Preoccupation with criticism or rejection in social situations
• Inhibition in new social situations due to feeling inadequate
• Feelings of being socially inept, unappealing, or inferior to others
• Hesitation to take risks or do new things out of fear of embarrassment

Most people with avoidant personality disorder do not seek treatment. When they do, it is often for a specific life problem they are experiencing or other types of symptoms such as depression and anxiety, and they will usually discontinue treatment if that problem is resolved.

Avoidant personality disorder can be hard to treat like other personality disorders because it is an enduring pattern of behavior and it can be difficult for the sufferer to recognize that psychotherapeutic help is needed and can be beneficial.

On the other hand, when treatment is successfully applied, it can help to reduce symptoms and increase the range of coping strategies that a person can use. A person with avoidant personality disorder will probably always be somewhat shy, but avoidance won't dominate his or her thoughts.

Talk therapy for avoidant personality disorder includes cognitive-behavioral therapy (CBT), psychodynamic therapy, and schema therapy. Group therapy and social skills training may also be helpful.

• CBT is helpful for learning how to change unhelpful thinking patterns.
• Psychodynamic therapy is aimed at being aware of how past experiences, pain, and conflict may be contributing to current symptoms.
• Schema therapy for avoidant personality disorder is an integrative approach that builds on CBT as well as many other therapeutic techniques. It has a focus on the therapeutic relationship between therapist and client, and a goal of improving daily functioning and gaining insight for change based on understanding and re-engineering of early life experiences.

In schema therapy, the client learns about four main concepts:

1. How maladaptive schemas are patterns that are repeated throughout life. These patterns are grouped into five areas: disconnection and rejection, impaired autonomy and performance, impaired limits, excessive responsibility and standards, over-vigilance and inhibition.
2. What coping styles were learned as a child (e.g., escape, fighting back).
3. What schema modes are being used to cope, and how they are unhelpful (e.g., avoidance, detachment, compliance, punishment).
4. How to develop healthy adult modes of coping and get core emotional needs met.

A key feature of schema therapy is "limited reparenting", in which the client expresses childhood needs and learns to develop and internalize a healthy parent voice.

While there are currently no medications specifically approved for avoidant personality disorder, if a person has other related disorders such as depression or anxiety, medication may be prescribed to help with these symptoms. For example, antidepressant medication can be helpful for improving mood and anhedonia, decreasing anxiety symptoms, and may also reduce sensitivity to rejection.

Avoidant personality disorder may co-occur and overlap with a variety of other conditions, including:

• Social anxiety disorder
• Dependent personality disorder
• Borderline personality disorder
• Substance abuse
• Depression
• Agoraphobia

If you think you, or someone you know or love may be living with avoidant personality disorder symptoms, it is important to encourage that person to seek help. Without professional treatment such as talk therapy, it is unlikely that the symptoms and their related impacts on relationships will improve.