Personality Disorders 101: Avoidant PD

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Today we move on to the Cluster C personality disorders, which are known as the “anxious” or “fearful” disorders. The first of these is Avoidant Personality Disorder (AvPD).

People who shied away from most social contact and activities were first discussed by Swiss psychiatrist Bleuler in 1911. Bleuler is better-known for coining the words schizophrenia and schizoid, and he interpreted people’s avoidance through that lens; he assumed severe social avoidance reflected an unnoticed type of schizophrenia. However, this opinion was not widely accepted, and by ten years later others viewed severe social avoidance as its own condition.

AvPD is leagues beyond being shy and introverted; instead, it is a deep-rooted and severe fear of rejection and criticism which affects almost every aspect of a person’s life. While someone with AvPD will want to connect with and develop friendships with others, their fear of being criticised and disapproved of can be so painful that they are unable to take part in social activities. Their self-loathing and feelings of inferiority may be so strong that they assume others would not want to interact with them. As a result they may interpret neutral statements as containing hidden rejections or reminders of their percieved social inability, which would reinforce their view of themselves being socially inadequate.

The DSM-5 describes AvPD as a widespread pattern of being inhibited around people, feeling inadequate and being very sensitive to being judged negatively. To be diagnosed with AvPD, someone must meet 4 of these criteria:

  • They avoid occupational activities that involve significant interpersonal contact, because they fear  criticism, disapproval, or rejection
  • They are unwilling to get involved with people unless they can be certain of being liked
  • They show restraint within close relationships because of the fear of being shamed or ridiculed
  • They are preoccupied with being criticized or rejected in social situations.
  • They are inhibited in new social situations because they feel inadequate
  • They seem themselves as socially inept, personally unappealing, or inferior to others
  • They are unusually reluctant to take personal risks or to engage in new activities in case they are embarrassing

No specific conditions need to be ruled out before a diagnosis of AvPD, but a psychiatrist would need to ensure substance abuse or a physical health condition did not cause the person’s symptoms. Approximately 2.3% of people in the USA (data is patchy for other countries) have been diagnosed with AVPD. While more people may fit the criteria, they may not be able to ask for help due to the fear of being rejected or judged. People may seek help for anxiety, or for feelings of depression which result from their experiences with AvPD, without anyone identifying the underlying AvPD traits.

One character who demonstrates many AvPD traits is Shinji Ikari, from the anime Neon Genesis Evangelion. While the typical anime hero is loud, brash, confident to a fault and very focused on others, Shinji is the opposite. He is described as “shrinking from human contact” due to his incredibly low self-worth, and although he wants to connect with others he expects to be judged negatively and rejected by them. He also continually doubts, and tries to run away from, his combat responsibilities; he reluctantly agrees to fight only when shown how other people would be harmed if he refused.

Social skills/awareness training and group therapy can help someone with AvPD practice connecting with others in a safe environment. It can also be used to help them evaluate their social behvaviours, as their anxiety can cause maladaptive social behaviours that lead to the rejection they fear. Medication can be used to reduce people’s accompanying anxiety, but there is no medication specifically for AvPD.

Psychological Criticisms of AVPD

AVPD is strongly linked to anxiety disorders; one study found that 22% of people diagnosed with Generalised Anxiety Disorder also met the criteria for AvPD. Social Anxiety Disorder (otherwise known as Social Phobia) also includes extreme shyness, social withdrawal, and feeling socially inept. The main difference is their prevalence; while ~7% of Americans in any given year could be diagnosed with social phobia, most will only fit the criteria for a short time.

As the two conditions share both symptoms and genetic vulnerabilities, some researchers believe AvPD is a severe form of social phobia rather than a separate condition. AvPD, in theory, could be the result of untreated social phobia affecting a person’s life so strongly that they meet the general personality disorder criteria. However, this is hard to study in more detail, partly because obtaining information and data from people with SP or AvPD can be difficult. Also, the DSM and ICD criteria for both conditions have changed slightly in each revision, resulting in a variable degree of overlap over time.

Critics of psychiatry often claim that social phobia (and sometimes AvPD) are examples of psychiatry making a medical issue out of shyness and introversion, and that people are labelled as impaired simply because they are different. While this argument holds for some mental health conditions due to how their diagnostic criteria have loosened in more recent editions of the DSM, this approach does not apply to AvPD. Instead, it ignores the negative consequences and life disruptions caused by the symptoms of AvPD.

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