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Day # 139: Avoidant Personality Disorder

Today we will continue our current theme of personality disorders as we begin to discuss the cluster C personality disorders. Today's topic is avoidant personality disorder.

Today's Content Level: Beginner and Intermediate

Introduction 1

  • Individuals with avoidant personality disorder (AVPD) have a long-standing pattern of social inhibition, feelings of inadequacy, and extreme sensitivity to rejection.

  • They often show a great desire for companionship, but are extremely shy and their fear of rejection is overwhelming. This leads them to avoid situations in which they may be rejected unless they have unusually strong guarantees of uncritical acceptance.

  • Avoidant personality disorder has a large overlap with social anxiety disorder (social phobia) and may be same syndrome/spectrum.

  • Common traits/symptoms may include being -> shy, avoidant, hypersensitive, cautious, fragile, timid, hesitant, easily embarrassed, and individuals often have an inferiority complex.

Diagnostic Criteria 2

  • The diagnosis of avoidant PD requires a pervasive pattern of hypersensitivity, social inhibition, and feelings of inadequacy beginning by early adulthood and present in a variety of contexts.

  • ≥4 of the following must also be present: Mnemonic "AFRAIDS"

  • Avoids - Avoids occupation that involves interpersonal contact due to a fear of criticism and rejection

  • Fear - Reluctant to engage in new activities for fear of embarrassment or criticism

  • Reserved - Unwilling to interact unless certain of being liked

  • Always thinking (preoccupied) - Preoccupied with being criticized or rejected in social situations

  • Inhibited - Inhibited in new social situations because they feel inadequate

  • Distance - Cautious of interpersonal relationships unless certan they are liked

  • Socially inept - Believes he or she is socially inept and inferior

Epidemiology/Pathogenesis 3, 4, 5

  • Prevalence is estimated to be 2-3% of the general population (estimates vary between 0.4-5%). Estimates are challenging since experts disagree about the validity of AVPD as an independent psychiatric disorder vs classifying it as a more severe variant of social anxiety disorder.

  • No clear information available regarding sex ratio. Some studies show equal frequency in men and women, while others suggest women may be slightly more predisposed.

  • As with all personality disorders, the dominant theory suggests avoidant PD develops from a combination of genetic vulnerability and environmental stressors.

  • Genetic predisposition (~0.64 heritability coefficient), infantile temperament, early childhood environment, and attachment style have all been associated with AVPD. The following infantile temperaments are associated with higher risk of AVPD-> high harm avoidance, low novelty seeking, rigidity, hypersensitivity, and overactive behavioral inhibition. The following parental approaches have also been associated-> dismissive responsiveness, minimal parental encouragement, caregiver guilt-engendering (shaming), neglect, and abuse.

  • Prognosis: Symptoms and behaviors are usually chronic but often show fewer symptoms as they age. AVPD is particularly difficult during adolescence when socialization and attractiveness are important. If their support system fails they are left very susceptible to anxiety and depressive disorders.

Clinical Pearls 4, 5, 6

  • History: Avoidant PD begins early in life and their fear of rejection is so overwhelming that it affects all aspects of their lives. They typically lead socially withdrawn lives and may seek vocations in which there is little interpersonal contact or opportunities for criticism. They desire companionship but often have no close friends or confidants because they find it difficult to enter relationships unless they are given an unusually strong guarantee of uncritical acceptance. Their dread of rejection may be reinforced by a repeated history of disappointing attempts at relationships which further exacerbates their feelings of self-blame, shame, and inadequacy. On the other hand some individuals are able to function in a more protected environment and may marry, have children, and live their lives surrounded mainly by family members or those they feel accept them.

  • Mental status exam: Hypersensitivity to rejection by others is the central clinical feature and may be seen in a few different ways during a clinical interview. Patients may appear anxious and tense and their mannerisms may wax and wane with their perception of whether an interview likes them. Alternatively, they may appear blunted or timid and their responses terse for fear of potential embarrassment of "saying something stupid". They may be vulnerable to even benign comments, suggestions, or clarifications and interpret them as criticism. It is important to create a tactful and gentle atmosphere in order to foster therapeutic alliance and allow the patient to be forthcoming.

  • Optional personality questionnaires: Personality Assessment Inventory (PAI), Minnesota Multiphasic Personality Inventory (MMPI), Social Phobia Inventory (SPIN), Liebowitz Social Anxiety Scale (LSAS).

  • Differential diagnosis: As mentioned previously, there is significant overlap for both AVPD and social anxiety disorder (SAD) and controversy exists around whether these two disorders should be merged since they are not distinguishable genetically or epidemiologically. Both involve fear and avoidance of social situations, however the SAD criteria is more specific to a particular social setting such as speaking in publics, eating in front of others, etc... Avoidant PD and schizoid PD are both socially avoidant, however patients with schizoid PD prefer to be alone and have little or no desire for companionship. Avoidant PD and dependent PD can look similar and both may cling to relationships, however dependent patients have a greater fear of being abandoned and actively and aggressively seek relationships.

Treatment 7, 8, 9

  • General approach to personality disorders: In general, the first-line treatment of all personality disorders is psychotherapy, however, the data is not robust and depending on the personality disorder, patients rarely seek treatment themselves unless they have other comorbid behavioral health conditions. Patients with personality disorders may be highly symptomatic and are often prescribed multiple medications in a manner unsupported by evidence.

  • Psychotherapy: Studies support the use of cognitive behavioral therapy (CBT). CBT, social skills training, assertiveness training, and graded exposure have all been reported to be helpful although the number of studies is small. Case reports of successful treatment with other psychological approaches exist such as psychodynamic therapy, acceptance and commitment therapy, and emotion focused therapy however controlled trials are lacking. The goals of therapy include -> understand themselves and their behavior, recognize their experiential and threat avoidance, improve communication and social skills, and develop self-compassion.

  • Pharmacotherapy: There are no FDA approved medications or randomized control trials for avoidant PD. However, clinical recommendations exist for using similar treatment approaches as for social anxiety disorder (SAD) such as SSRIs or SNRIs. SSRIs or SNRIs may improve social anxiety and rejection sensitivity. Some patients are helped by beta-blockers, such as propranolol, to manage autonomic nervous system hyperactivity which tends to be high in patients with avoidant PD when they approach feared situations. Expectations for treatment response should be attenuated and the potentially limited benefits must outweigh the risks associated with medication treatment. Comorbid anxiety and depressive disorders should be treated accordingly (see treatment of depression; treatment of anxiety).


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