The Oxford Handbook of Personality Disorders
Chapter 25
Avoidant personality disorder

Introduction

Avoidant personality disorder (AVPD) is characterized by a desire for affiliation coupled with a sense of personal inadequacy and intense fears of interpersonal rejection. A heightened sensitivity to criticism and expected condemnation by others are key features of AVPD.

Approximately 1.6% of individuals suffer from AVPD.

The modern diagnosis of avoidant personality disorder

DSM-IV-TR definition and criteria

AVPD is characterized by a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.

At least four of any of the seven criteria to meet the diagnostic threshold for AVPD: 1) Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval or rejection. 2) is unwilling to get involved with people unless certain of being liked 3) shows restraint within intimate relationships because of the fear of being shamed or ridiculed. 4) is preoccupied with being criticized or rejected in social situations 5) is inhibited in new interpersonal situations because of feelings of inadequacy 6) views self as socially inept, personally unappealing, or inferior to others 7) is unusually reluctant to take personal risk or to engage in any new activities because they may prove embarrassing.

Evolution of the avoidant personality disorder construct: 1980-2010

Avoidant personality disorder and DSM diagnostic co-occurrence

Comorbidity of AVPD is the norm.

Disorders frequently co-occurring with avoidant personality disorder

AVPD frequently co-occurs with a spectrum of anxiety and depressive disorders.

Avoidant personality disorder and social phobia

The DMS diagnosis of social phobia is characterized by a fear or avoidance of social situations that is presumably more circumscribed than AVPD. But, there is considerable overlap, it is more likely to be a continuum..

Personality traits may be an important distinction.

Other comorbide dsm conditions

Another personality disorder that overlaps or may share features with AVPD is dependent personality disorder. The key distinction is that AVPD is driven by fear of being rejected.

Avoidant personality disorder and the five-factor model

Two domains that are relevant to AVPD are (high) neuroticism and (low) extraversion. Neuroticism is composed of the facets: anxiety, angry hostility, depression, self-consciousness, impulsiveness and vulnerability.

Extraversion is composed of the facets: warmth, gregariousness, assertiveness, activity, excitement seeking and positive emotions.

Avoidant personality disorder comorbidity revisited in the context of the five-factor model

Comorbidity can be understood as occurring due to overlap of certain personality traits.

Avoidant personality disorder comorbidity: commentary

It is important to keep in mind that AVPD is a diagnostic construct.

Mechanisms and theories

Psychodynamic perspectives

Psychodynamic theories, focus mainly on the idea of a phobic character. The phobic character is more prototypically schizoid. For psychoanalytic and object relation theorist, the labels ‘schizoid’ and ‘false-self’ are also key representations of the developmental history. The pattern of avoidance is a defence against potentially painful or overwhelming affect.

Horney focused on the avoidant style as one avenue to resolve inner conflicts revolving around attachment. For the detached character, the anxiety that comes with relatedness and thus drives a need to be self-sufficient. This sets the need for hypercompetence, a standard that is so high that it will lead to disappointment in one’s own abilities. In schizoid PD, it is often the case that the affected individual is able to develop self-sufficiency despite the presence of other deficits. For the avoidant individual, internalized critical self-objects attacks are experienced unrelentingly, stemming back form early experiences.

Interpersonal origins and maintenance of avoidant personality disorder

The structural analysis for interpersonal behaviour codes patterns of interpersonal behaviour that one has repeatedly experiences as they relate to how a person perceives both the self and other.

AVPD persons live in a state of expecting degrading, humiliating attack. Their self-protective response to this possibility is social withdrawal. This promotes a perception of others that borders on paranoid, as well as reliance on safety at home that can sap the resources of the few individuals with whom the AVPD person has a relationship.

The difficult interpersonal transactions came later.

Biological and cognitive structures

Those who were less sensitive to rejection showed greater activity in the left prefrontal cortex, along the inferior frontal gyurs and the right dorsal superior frontal gyrus.