9. Avoidant personality disorder

Cluster C comprises avoidant, dependent, and anankastic personality disorder. In avoidant personality disorder, the person is persistently tense because he or she believes that he or she is socially inept, unappealing, or inferior, and as a result fears being embarrassed, criticised, or rejected. He or she avoids meeting people unless he or she is certain of being liked, is restrained even in his or her intimate relationships, and avoids taking risks. Avoidant personality disorder is strongly associated with anxiety disorders, and may also be associated with actual or perceived rejection by parents or peers during childhood.

Avoidant Personality Disorder Symptoms

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People with avoidant personality disorder experience long-standing feelings of inadequacy and are extremely sensitive to what others think about them. These feelings of inadequacy leads to the person to be socially inhibited and feel socially inept. Because of these feelings of inadequacy and inhibition, the person with avoidant personality disorder will seek to avoid work, school and any activities that involve socializing or interacting with others.
Individuals with Avoidant Personality Disorder often vigilantly appraise the movements and expressions of those with whom they come into contact. Their fearful and tense demeanor may elicit ridicule from others, which in turn confirms their self-doubts. They are very anxious about the possibility that they will react to criticism with blushing or crying. They are described by others as being “shy,” “timid,” “lonely,” and “isolated.”
The major problems associated with this disorder occur in social and occupational functioning. The low self-esteem and hypersensitivity to rejection are associated with restricted interpersonal contacts. These individuals may become relatively isolated and usually do not have a large social support network that can help them weather crises. They desire affection and acceptance and may fantasize about idealized relationships with others. The avoidant behaviors can also adversely affect occupational functioning because these individuals try to avoid the types of social situations that may be important for meeting the basic demands of the job or for advancement.
A personality disorder is an enduring pattern of inner experience and behavior that deviates from the norm of the individual’s culture. The pattern is seen in two or more of the following areas: cognition; affect; interpersonal functioning; or impulse control. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. It typically leads to significant distress or impairment in social, work or other areas of functioning. The pattern is stable and of long duration, and its onset can be traced back to early adulthood or adolescence.

Symptoms of Avoidant Personality Disorder

Avoidant personality disorder is characterized by a long-standing pattern of feelings of inadequacy, extreme sensitivity to what other people think about them, and social inhibition. It typically manifests itself by early adulthood and includes a majority of the following symptoms:

• 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 relationshipsbecause of the fear of being shamed or ridiculed
• Is preoccupied with being criticized or rejected in social situations
• Is inhibited in new interpersonal situations because of feelings of inadequacy
• Views themself 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 may prove embarrassing

Because personality disorders describe long-standing and enduring patterns of behavior, they are most often diagnosed in adulthood. It is uncommon for them to be diagnosed in childhood or adolescence, because a child or teen is under constant development, personality changes and maturation. However, if it is diagnosed in a child or teen, the features must have been present for at least 1 year.
Avoidant personality disorder appears to occur in 2.4 percent in the general population, according to 2002 NESARC research.
Like most personality disorders, avoidant personality disorder typically will decrease in intensity with age, with many people experiencing few of the most extreme symptoms by the time they are in the 40s or 50s.

How is Avoidant Personality Disorder Diagnosed?

Personality disorders such as avoidant personality disorder are typically diagnosed by a trained mental health professional, such as a psychologist or psychiatrist. Family physicians and general practitioners are generally not trained or well-equipped to make this type of psychological diagnosis. So while you can initially consult a family physician about this problem, they should refer you to a mental health professional for diagnosis and treatment. There are no laboratory, blood or genetic tests that are used to diagnose avoidant personality disorder.
Many people with avoidant personality disorder don’t seek out treatment. People with personality disorders, in general, do not often seek out treatment until the disorder starts to significantly interfere or otherwise impact a person’s life. This most often happens when a person’s coping resources are stretched too thin to deal with stress or other life events.
A diagnosis for avoidant personality disorder is made by a mental health professional comparing your symptoms and life history with those listed here. They will make a determination whether your symptoms meet the criteria necessary for a personality disorder diagnosis.

Causes of Avoidant Personality Disorder

Researchers today don’t know what causes avoidant personality disorder. There are many theories, however, about the possible causes of avoidant personality disorder. Most professionals subscribe to a biopsychosocial model of causation — that is, the causes of are likely due to biological and genetic factors, social factors (such as how a person interacts in their early development with their family and friends and other children), and psychological factors (the individual’s personality and temperament, shaped by their environment and learned coping skills to deal with stress). This suggests that no single factor is responsible — rather, it is the complex and likely intertwined nature of all three factors that are important. If a person has this personality disorder, research suggests that there is a slightly increased risk for this disorder to be “passed down” to their children.

Treatment of Avoidant Personality Disorder

Treatment of avoidant personality disorder typically involves long-term psychotherapy with a therapist that has experience in treating this kind of personality disorder. Medications may also be prescribed to help with specific troubling and debilitating symptoms. For more information about treatment, please see avoidant personality disorder treatment.

Avoidant Personality Disorder

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Avoidant personality disorder is characterized by feelings of extreme social inhibition, inadequacy, and sensitivity to negative criticism and rejection. Yet the symptoms involve more than simply being shy or socially awkward. Avoidant personality disorder causes significant problems that affect the ability to interact with others and maintainrelationships in day-to-day life. About 1% of the general population has avoidant personality disorder.

Avoidant Personality Disorder Symptoms

Avoidant personality disorder symptoms include a variety of behaviors, such as:

• Avoiding work, social, or school activities for fear of criticism or rejection. It may feel as if you are frequently unwelcome in social situations, even when that is not the case. This is because people with avoidant personality disorder have a low threshold for criticism and often imagine themselves to be inferior to others.
• Low self-esteem
• Self-isolation

When in social situations, a person with avoidant personality disorder may be afraid to speak up for fear of saying the wrong thing, blushing, stammering, or otherwise getting embarrassed. You may also spend a great deal of time anxiously studying those around you for signs of approval or rejection.

A person who has an avoidant personality disorder is aware of being uncomfortable in social situations and often feels socially inept. Despite this self-awareness, comments by others about your shyness or nervousness in social settings may feel like criticism or rejection. This is especially true if you are teased, even in a good-natured way, about your avoidance of social situations.

Social Impact of Avoidant Personality Disorder

Avoidant personality disorder causes a fear of rejection that often makes it difficult to connect with other people. You may be hesitant to seek out friendships, unless you are certain that the other person will like you. When you are involved in a relationship, you may be afraid to share personal information or talk about your feelings. This can make it difficult to maintain intimate relationships or close friendships.

According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a person diagnosed with avoidant personality disorder needs to show at least four of the following criteria:

• Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection.
• Is unwilling to get involved with people unless they are 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 situations.
• 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 may prove embarrassing.

Avoidant behavior may commonly be seen in children or adolescents, but a diagnosis of a personality disorder cannot be made in childhood because shyness, fear of strangers, social awkwardness, or being sensitive to criticism are often a normal part of child and adolescent development.

A mental health professional can assess your symptoms, make an accurate diagnosis, and suggest the appropriate treatment options.

Avoidant Personality Disorder Treatments

As with other personality disorders, a mental health professional will design a treatment plan that is appropriate for you. Avoidant personality disorder treatments vary, but they will likely include talk therapy. If a co-existing condition, such as depression or anxietydisorder, is also diagnosed, appropriate medications may also be used.

Avoidant Personality Disorder and Other Conditions

Other mental health disorders can occur along with avoidant personality disorder. Treatments in these cases will be designed to help with the symptoms of each disorder. A few of the conditions that most frequently occur with avoidant personality disorder include:

• Social phobia, in which a person experiences overwhelming anxiety and self-consciousness in common social situations. 
• Dependent personality disorder, in which people rely excessively on others for advice or to make decisions for them. 
• Borderline personality disorder, in which people have difficulties in many areas including social relationships, behavior, mood, and self-image.

Many avoidant personality disorder symptoms are commonly shared among these other conditions, particularly in the case of generalized social phobia. Because of this, the disorders can be easily confused. It may take some time for a mental health professional to make a clear diagnosis and choose the appropriate treatments for you.

Avoidant personality disorder

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Avoidant personality disorder is a mental health condition in which a person has a lifelong pattern of feeling very shy, inadequate, and sensitive to rejection.

Causes

Cause of avoidant personality disorder is unknown. Genes or a physical illness that changed the person's appearance may play a role. About 1% of the population has avoidant personality disorder.

Symptoms

People with this disorder cannot stop thinking about their own shortcomings. They form relationships with other people only if they believe they will not be rejected. Loss and rejection are so painful that these people choose to be lonely rather than risk trying to connect with others.

A person with avoidant personality disorder may:

• Be easily hurt when people criticize or disapprove of them
• Hold back too much inintimate relationships
• Be reluctant to become involved with people
• Avoid activities or jobs that involve contact with others
• Be shy in social situations out of fear of doing something wrong
• Make potential difficulties seem worse than they are
• Hold the view they are not good socially, not as good as other people, or unappealing

Exams and Tests

Avoidant personality disorder is diagnosed based on a psychological evaluation that assesses the history and severity of the symptoms.

Treatment

Talk therapy is considered to be the most effective treatment for this condition. It helps persons with this disorder be less sensitive to rejection. Antidepressant drugs may be used in addition.

Outlook (Prognosis)

People with this disorder may develop some ability to relate to others. With treatment this can be improved.

Possible Complications

Without treatment, a person with avoidant personality disorder may lead a life of near or total isolation. They may go on to develop a second mental health disorder such as substance abuse or a mood disorder such as depression.

When to Contact a Medical Professional

See your health care provider or a mental health professional if shyness or fear of rejection overwhelms your ability to function in life and have relationships.

Alternative Names

Personality disorder - avoidant

References

Blais MA, Smallwood P, Groves JE, Rivas-Vazquez RA. Personality and personality disorders. In: Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 1st ed. Philadelphia, PA: Elsevier Mosby; 2008;chap 39.

Update Date: 11/17/2012

Updated by: Timothy Rogge, MD, Medical Director, Family Medical Psychiatry Center, Kirkland, WA. Also reviewed by A.D.A.M. Health Solutions, Ebix, Inc., Editorial Team: David Zieve, MD, MHA, David R. Eltz, Stephanie Slon, and Nissi Wang