Source: Ryanniel Manuscol/Pexels

Avoidant personality disorder (AvPD) isn’t as well-known as narcissistic or borderline personality disorder, but that doesn’t mean it’s uncommon. In fact, some researchers tell us that AvPD was the most frequently occurring personality disorder in three epidemiological studies. It was reported as between 5.1 and 55.4 percent prevalence in clinical settings (Sperry & Casteliero, 2022).

While interpersonally-avoidant characteristics occur in social phobia, autism, and schizoid and schizotypal personalities, the avoidant personality is a unique character that is frequently unrecognized. In fact, researchers Reich & Schatzburg (2021) noted, “AvPD is an important clinical issue because it is prevalent in the community and has high morbidity and high heritability. Its single factor seems to suggest evaluation and treatment should be straightforward, but despite this, it tends to be underdiagnosed and undertreated.”

With this in mind, being aware of and able to recognize AvPD is the big first step. Readers may be wondering if AvPD is simply a more ingrained social phobia. It’s true that researchers and clinicians have debated for years whether these two conditions exist on a continuum (e.g., Turner et al., 1986; Reich, 2000; Sperry & Casteliero, 2022) but, regardless, it can’t be ignored that social phobia is more of a performance anxiety, while AvPD is much more of a pervasive interactive style and the way the person has “always been.”

Further, those with AvPD tend to have greater functional impairment than social phobia, given the avoidance pattern is much greater (APA, 2022), and it often co-occurs with other personality disorders, including dependent and borderline, which are both significantly impairing in themselves.

Three major red flags in avoidant personality disorder

1. Social avoidance in AvPD isn’t fueled only by fear of doing or saying something that could bring embarrassment or social scrutiny, like when someone is the center of attention for some reason or feeling like they don’t fit in. While this fear is present, the avoidant personality’s avoidance is generated by the core belief that “I’m so inept, undesirable, and stupid that others couldn’t possibly want to associate with me or take me seriously. My undesirable characteristics are irrepressible and easily detected, and therefore, I’ll always be seen as ‘less-than.’”

In effect, it’s negative self-evaluation in comparison to others, a matter of self-esteem. This pattern isn’t something that seems to develop like a phobia. Rather, the person has “always been this way” and, since early on, has been experienced as uneasy and unusually shy or timid.

2. While avoidant, those with AvPD aren’t necessarily hermits. Instead, the handful of people they have let in have likely had to prove many times over that they are not judgmental and have made many gestures to the person that their company is desirable. Also, in terms of dating relationships, they might have a penchant for being attracted to someone they can feel superior to. People with AvPD I’ve worked with often complain about their partners’ inadequacies.

Further, once in a relationship, despite the steady flow of complaints, the AvPD person hesitates to discontinue the relationship because a) they rely on having someone to devalue, b) there’s an assumption they’ll never find someone again, or at least someone that will accept them and is a safe target as needed, and c) there are also dependent and borderline personality characteristics at hand, both of which have a penchant for clinginess.

3. Someone with AvPD likely has a rich fantasy life involving idealized relationships and life accomplishments to obtain some sense of gratification. An acquaintance of mine with characteristics of AvPD once lamented their lack of risk-taking to capitalize on their photography skills, build their own business, and leave the area where they were raised. When asked to provide more details, they explained, “Oh, I’m no good at promoting myself or trying to fit in elsewhere. I’m just a dreamer.”

In addition, the fantasies in AvPD probably involve resolving interpersonal conflicts. Many with AvPD seem to cast themselves in an assertive, or perhaps even heroic, light to compensate for their real-life deficits. Theodore Millon (2011) noted, “But fantasies also prove distressing in the long run because they point out the contrast between desire and objective reality.”

 

Source: Cottonbro/Pexels

Treatment implications

Like people with untreated social phobias, those with AvPD are not only anxious but also tend to harbor significant depression and substance abuse issues (APA, 2022). It’s easy to see how interpersonal avoidance, from not having satisfying relationships and jobs to conflict resolution, can be depressing. Some have told me, “It’s like watching everyone else have a life.” Chemical dependency can arise as self-medication, and substances, especially alcohol, may not only take the edge off but facilitate socializing. It’s often this clinical cocktail, particularly the depression and substance abuse, that initially brings someone with AvPD to treatment, where it’s discovered that personality dynamics are driving the suffering.

The good news is that AvPD can respond well to intervention (e.g., Beck & Freeman, 1990; Millon, 2011; Simonsen et al., 2022; Sperry & Casteliero, 2022). The therapist’s best asset may be patience, as successful treatment, provided the patients’ timidity, will likely begin with a particularly delicate rapport-building phase. This is no different from the AvPD’s need to carefully investigate colleagues, friends, etc., for signs of criticism before allowing any exposure. AvPD, unlike social phobia, which may improve within months with cognitive-behavioral interventions like exposure therapy (e.g., ADAA, 2021), will likely involve longer-term investment to ingrain more constructive ways of relating.

Disclaimer: The material provided in this post is for informational purposes only and is not intended to diagnose, treat, or prevent any illness in readers or people they know. The information should not replace personalized care or intervention from an individual’s provider or formal supervision if you’re a practitioner or student.