Avoidant personality disorder (AvPD), or anxious personality disorder,Anxious [avoidant personality disorder] in ICD-10: Diagnostic Criteria and Clinical descriptions and guidelines. is a personality disorder characterized by marked social inhibition and avoidance, accompanied by feelings of inadequacy and a strong sensitivity to rejection or negative evaluation. People with AvPD may therefore avoid social interaction, while at the same time strongly desiring more involvement with other people.
Not precisely known, the causes of AvPD are believed to involve several environmental and genetic factors. The disorder is chronic, and research is limited with regard to its treatment. Treatment and time may allow for the condition to be ameliorated. Ostensibly, it affects a similar number of women as it does men, with some indication of a higher prevalence among women.
There are two definitions of AvPD in the Diagnostic and Statistical Manual of Mental Disorders since the publication of its fifth edition (DSM-5); the primary definition is categorical, while the other is derived from a dimensional model. The most recent revision (ICD-11) of the International Classification of Diseases does not specifically include AvPD or other specific personality disorders, having replaced such diagnoses with a dimensional classification system. Signs and symptoms Characteristically, people with AvPD have a tendency to view themselves as inferior to other people, believing that they are unappealing and have inadequate social skills, and they worry extensively about being rejected or subjected to criticism and ridicule. This may consequently lead them to be wary about social interaction and self-disclosure, in the absence of reassurance from others that they are accepted. This, in turn, is contrasted with them usually desiring interpersonal relationships, without which they experience a deep sense of loneliness.
People with AvPD believe themselves to be inferior to others in various aspects, expecting to be criticized for those shortcomings, accompanied by the belief that others will persistently think negatively of them. In order to avoid subjection to criticism, a person with AvPD may abstain from entering friendships, taking part in group activities or accepting a job offer or promotion. They may therefore also specifically strive to obtain a job requiring little interaction with others. In the presence of others, they are disinclined to perform activities or share personal thoughts and feelings that may result in embarrassment; instead, they may, for example, wait for an opportunity to agree with what someone else says.
Some with this disorder fantasize about idealized relationships. They often think of themselves as unworthy of the relationships they desire, and shame themselves from ever attempting to begin them. Someone with AvPD may rigorously test whether others will reliably approve of them. If they can ascertain that they will be accepted without criticism, an intimate relationship is a feasible prospect. At the same time, they may have difficulty being vulnerable through self-disclosure and sharing their feelings. It is common that they pre-emptively abandon relationships, fearing that they will fail.
They are likely to vigilantly monitor others' expression, and may erroneously perceive criticism in other's comments about them. Even minor expressions of disapproval may feel upsetting to someone with AvPD. Expressing a reticent and fearful demeanor, their behavior may include a discernible aversion to eye contact and limited speech; when they speak, they are likely to be self-effacing, downplaying their accomplishments. Moreover, their lack of confidence in themselves may be exacerbated by others mocking their apparent fearfulness.
Causes
With research on the matter being limited, the etiology of AvPD has not yet been thoroughly elucidated. Findings suggest that several factors may contribute to the development of the disorder; these include early childhood experiences, genetics, temperament, and environment. The significance of these factors relative to each other remains uncertain.
A genetic contribution to AvPD is suggested by an estimated heritability coefficient of 0.64 that was found in a population-based twin study. Regarding temperamental traits, behavioral inhibition, shyness, negative emotionality, and high harm avoidance have been linked to AvPD. These traits may increase vulnerability to adverse childhood experiences. They may also influence the development and use of avoidant coping strategies. Moreover, people with AvPD have reported experiences of neglect, abuse, lower care, and overprotection in childhood; however, recall bias may influence such reports. Because twin studies have suggested an environmental component in the etiology of AvPD, such childhood experiences have been proposed as possible environmental contributors.
Diagnosis
Classification Classification of personality disorders differs significantly between the frameworks incorporated into the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD). The DSM-5 includes two distinct diagnostic models for personality disorders; its main body (Section II) retains a traditional, categorical model of 10 putatively distinct PDs, whereas the hybrid categorical–dimensional Alternative DSM-5 Model for Personality Disorders (AMPD) is based on impairment in personality functioning as well as pathological personality traits, based on which PD diagnoses are constructed. In the ICD-11, a dimensional model of personality disorders is implemented. Similarly to the AMPD, it is based on severity and pathological traits; however, it does not classify PD as types, and characterization of the disorder through trait qualifiers is optional. The introduction of the AMPD and the ICD-11 classification of personality disorders reflects a broader transition towards dimensional PD models.
DSM-5 In the categorical DSM-5 classification of personality disorders, AvPD is described as "a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation", for a diagnosis of which at least four out of seven diagnostic criteria must be met. The polythetic nature of this approach results in heterogeneity within the diagnosis, which can manifest as two people receiving the same diagnosis while only one criterion is met by both of them; however, research has suggested that the AvPD construct, as described in the DSM-IV-TR, is unidimensional. This classification system groups personality disorders into three clusters, with AvPD belonging to cluster C, which is a cluster characterized by anxious and fearful presentations.
AMPD Contained within Section III of the DSM-5 as an alternative to the categorical model, the AMPD defines six specific personality disorders – one of them being AvPD – based on particular constellations of the characteristic manner in which the disorder impacts personality functioning, as manifested in impairments in the identity, self-direction, empathy and intimacy domains (criterion A), as well as a set of pathological personality traits characterizing the disorder (criterion B). While criterion A thus captures the severity of the disorder, criterion B characterizes its "style".
At least two of the elements of personality functioning must have a "moderate or greater impairment", manifesting in, for example, the following being true for the identity domain: "[l]ow self-esteem associated with self-appraisal as socially inept, personally unappealing, or inferior; excessive feelings of shame". The AMPD lists the following four pathological traits: anxiousness, withdrawal, anhedonia, and intimacy avoidance; each of these is followed by a description of how the trait manifests in AvPD, such as "reticence in social situations; avoidance of social contacts and activity; [and] lack of initiation of social contact" in the case of withdrawal. A diagnosis requires that three of these traits are present in the subject, with anxiousness being required. Furthermore, additional traits can be added as specifiers to the diagnosis. Further requirements, for example relating to differential diagnosis, are embodied in criteria C–G.
ICD-11 With the introduction of the ICD-11, categories of personality disorder were abolished in favor of a system in which personality disorder is instead classified by severity, with specification of traits or a borderline pattern being optional. Severity is assessed based on the degree and pervasiveness of disturbance in the person’s relationships and their sense of self; the intensity and breadth of the emotional, cognitive and behavioral manifestations of the person’s disturbance; the extent to which these patterns and problems cause distress or psychosocial impairment; and the level of risk of harm to self and others. Trait and pattern specifiers are used for recording the manner in which the disturbance is manifested. Anxious (avoidant) personality disorder has been found to be consistently associated with the ICD-11 trait domains Negative Affectivity and Detachment, reflecting anxiousness, low self-esteem, and social withdrawal. The complete Avoidant PD pattern of Negative Affectivity and Detachment is overall consistent with the description of people with AvPD as being both fearful and emotionally inhibited. Many studies also report a link to Anankastia, likely due to features such as emotional restraint and excessive caution aimed at avoiding negative outcomes.
Differential diagnosis In the case of AvPD, differential diagnosis primarily concerns social anxiety disorder (SAD), which has significant similarities to AvPD, with the distinction between the two being a matter of inquiry. Another personality disorder diagnosis could also be more suitable for a presentation considered for a diagnosis of AvPD; however, these can otherwise be diagnosed alongside AvPD, provided that the requirements for diagnosis are met for all of them (see ). Specifically, dependent, paranoid, schizoid and schizotypal personality disorders share features with AvPD while being possible to distinguish from it based on characteristic differences.
The relationship between AvPD and SAD has been a topic of debate, with research conducted in order to elucidate the matter. They have similar features and diagnostic criteria, and research shows similarities in etiology, response to treatment, and deficits in quality of life. This has lead to the conceptualization of the two as being the same disorder at different levels of severity, with AvPD being more severe than SAD. This "severity continuum hypothesis" is further supported by research showing that, when controlled for the severity of social anxiety, differences in impairment between the two disappear. Other research, specifically conducted using criteria from the DSM-IV, has however not consistently shown AvPD to be more severe, challenging the aforementioned hypothesis; changes in diagnostic criteria across editions of the DSM have been significant for research on the distinction between the two disorders. The separation may also find support in that about two thirds of those diagnosed with AvPD do not meet criteria for SAD. The "social fears seem to be more 'ingrained' in the self-concept" in the case of AvPD, and features such as "restraint in intimate relationships", lower self-respect, and "higher emotional guardedness" may be considered specific to AvPD. As opposed to this, SAD more typically relates to anxiety in situations, rather than to relationships in general.