Avoidant Personality Disorder (AVPD)
OVERVIEW
Avoidant Personality Disorder (AVPD) is a personality disorder defined by pervasive patterns of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.[1] It often begins in early adulthood and continues across different contexts.[2,3] As a personality disorder, AVPD is often persistent throughout a person's lifetime and includes significant impairments in personality functioning due to fears of criticism, disapproval, or rejection. It is also one of the most common personality disorders: in community samples, there is a 1.7%-2.7% median lifetime prevalence of AVPD, and 14.7% of psychiatric outpatients report AVPD as a comorbid disorder.[4,5]
DIAGNOSIS
According to the DSM-5, to be diagnosed with AVPD, patients must meet four or more of the following criteria:
avoidance of occupational activities involving significant interpersonal contact,
unwillingness to form relationships unless certain of being liked,
restraint within intimate relationships,
preoccupation with being criticized or rejected in social situations,
inhibition in new interpersonal situations,
self-image as socially inept or inferior to others, and
reluctance to take personal risks or engage in any new activities.[6]
In addition, significant impairments in personality functioning manifest through impairments in self-functioning and interpersonal functioning, as well as maladaptive personality traits. Self-functioning involves identity (in which AVPD patients may feel low self-esteem associated with their self-image as socially inept) as well as self-direction (in which they set unrealistic standards for behavior associated with their reluctance to pursue goals, take risks, or engage in new activities).[7] Interpersonal functioning, on the other hand, involves empathy (in which sensitivity to criticism or rejection is associated with distorted interpretations of others' perspectives as negative) as well as intimacy (where there is a diminished mutuality within intimate relationships for fear of being shamed or ridiculed).[8]
Maladaptive personality traits often include detachment. In patients, this is seen most commonly in withdrawal from social situations, intimacy avoidance, and anhedonia, a symptom where a person has difficulty feeling pleasure and interest in life's experiences. These traits also often include negative affectivity, which mainly manifests in anxiousness. This nervousness can be in reaction to present social situations, as well as the negative effects of past unpleasant experiences and apprehension for future uncertainties.[9,10] In addition, AVPD may involve deficits in theory of mind and mentalization, the ability to understand the mental state of others, as well as associations with alexithymia, a difficulty with feeling emotions–although there is debate whether these can be attributed to true cognitive deficits or psychological defense mechanisms against distress.[11]
SYMPTOMS
Lampe & Malhi (2018) have found that patients report a variety of symptom sets in the development of AVPD.[12] Such symptoms involve longing to relate to others, frustration over oversensitivity to social stimuli, and hyperreactivity to the feelings of others. They can also feel self-doubt and mistrust of other people, reticence in social situations, and diminished eye contact. Additionally, people can develop a malignant self-regard after attributing the fault of repeated frustrating relationships to oneself, and can experience feelings of hypersensitive self-focus, perfectionism, and difficulty expressing anger.[13,14]
These traits can create mental distress and, accordingly, pronounced impairments in daily life; AVPD is correlated with low self-efficacy, lower levels of education and income, and somatic disorders.[15] AVPD is often comorbid with depression and substance abuse, and is associated with increased odds of suicidal ideation, anorexia nervosa, and binge-eating disorder.[16] In fact, AVPD is considered to have the highest level of daily functioning challenges of all personality disorders.[17]
DIAGNOSIS OVERLAP
When diagnosing AVPD, it is important to differentiate symptoms from similar anxiety and personality disorders with significant overlap. Because of the similarities and comorbidities between several disorders, it can be difficult to make an accurate diagnosis; it was originally believed that AVPD only occurred in association with social anxiety disorder.[18] However, studies of patient populations found that two-thirds of those with AVPD do not meet the additional criteria for SAD, demonstrating a need to delineate the two conditions.[19]
In the DSM's third edition, the diagnoses of AVPD and SAD were hierarchical. Because AVPD was a higher-order diagnosis, it precluded a diagnosis of SAD. This followed the "severity continuum hypothesis," that AVPD was simply a more severe form of SAD.[20,21] This overlap between the two conditions is demonstrated by the fact that they have the most common comorbid diagnosis, with comorbidity ranging from 40-88%, in addition to involving similar social fears and high levels of social anxiety.[22] However, as comorbidities, the two conditions combine to create greater symptom burden and distress, greater disability, and more functional impairment, leading the DSM-IV to differentiate the two. AVPD diagnoses now also involve fears of rejection and feelings of inadequacy driving avoidance, and AVPD is not always more severe than SAD.[23] Other symptoms specific to AVPD may be a sense of inferiority and passivity, in addition to emotional guardedness and lack of self-respect.[24]
AVPD also holds some overlap with schizoid personality disorder. Conceptually, AVPD relates to the social anxiety components in schizophrenia spectrum disorders.[25] In addition, increased rates of both AVPD and schizoid PD are reported in relatives of individuals at high risk of psychosis.[26] However, social anhedonia is the key differentiation between the two personality disorders. While those with schizoid personality disorder experience underarousal, insensitivity to social cues, and lack of interest in relationships, those with AVPD experience a desire for affection and acceptance that is unmet.[27]
Finally, AVPD shares similarities with dependent personality disorder: both involve feelings of inadequacy, a need for reassurance, and hypersensitivity to criticism.[28] As a comorbidity, 59% of dependent PD individuals also have AVPD.[29] Different levels of social withdrawal exist between the two PDs, however. Those with AVPD display unassertiveness due to a fear of rejection and humiliation; contrastingly, those with DPD are proximity-seeking, approaching others due to a desire to avoid being abandoned and left to fend for themselves.[30]
CONTRIBUTING FACTORS
Several factors are theorized to contribute to developing avoidant personality disorder. A number of temperamental traits have been correlated with an increased vulnerability towards AVPD, particularly since temperament can influence a person's selection of maladaptive coping strategies during difficult experiences. Such traits include personality rigidity, hypersensitivity, high harm avoidance, low novelty-seeking, overactive behavioral inhibition systems, negative emotionality (neuroticism), behavioral inhibition, shyness, and depressive symptoms such as negative affect and fear of negative evaluation.[31,32]
Genetic influences on AVPD are still under study, though it has been found to have a heritability coefficient of 0.64 based on twin studies.[33,34] In line with this finding, first-degree relatives of individuals with social anxiety disorder are 3-4 times more likely to have a diagnosis of AVPD. Studies disagree whether there are notable brain differences in patients with AVPD; Denny et al. (2016) found a link between amygdala hyper-reactivity in AVPD patients relative to healthy controls, while Koenigsberg et al. (2014) did not find the same result in a similar experiment.[35] Regardless, research suggests that genetic influences stabilize in early adulthood, when the environment generally takes over to contribute to the maintenance of AVPD symptoms.[36]
Cognitive behaviorists suggest that AVPD may involve deficits in mentalization and theory of mind, leaving patients with difficulty understanding the mental states of others and connecting socially.[37] However, proponents of psychodynamic theory note the impact of childhood experience on the development of avoidant behaviors, where avoidance is used as a defense mechanism against traumatic experiences.[38] As evidence of a potential early childhood link to AVPD, there is a nearly doubled chance of developing AVPD in a person who was adopted, compared to non-adoptees. Adoptees' childhoods are often associated with fewer positive relationships with adults, resulting in an increased chance of developing an insecure attachment style.[39]
To understand attachment styles, maladaptive attachments often involve schemas of belief in the need to subjugate one's personal needs to avoid negative relation outcomes.[40] Such subjugation can lead to hypervigilance, avoidance, low self-esteem, and negative self-concept, which are maladaptive coping strategies that then become generalized to other social situations as the patient ages. Westen et al. (2006) notes that avoidant infants are often indifferent or ignore the return of a caregiver after separation, leading them as adults to have dismissive discourse minimizing the importance of their attachment–either idealizing their painful relationships or diminishing the importance of their parents.[41] In addition to avoidant attachment individuals, individuals with fearful attachment had the highest likelihood of at least one personality disorder diagnosis–particularly AVPD–while preoccupied attachment was also linked with AVPD.[42]
IMPACT OF COVID-19
Personality disorders like AVPD have been exacerbated by the COVID-19 pandemic: isolation and moves into virtual formats facilitate avoidance behaviors. In Norway, in-person mental health services were completely shut down during the pandemic. A survey was distributed to twelve personality disorder treatment units in Norway, where AVPD and borderline personality disorder patients were most common. The survey found that during the pandemic, 81% of respondents had experienced an impairment of personality functioning.[43] Additionally, they reported problem increases in anxiety (28%), depression (24%), aggression (23%), and substance use (14%), with a majority (78%) reporting increased or unchanged social isolation and loneliness.[44] For those experiencing AVPD, social isolation even further emphasizes the unmet need for relationships and security.
In Italy, where the country underwent a nationwide lockdown in March 2020, Sica et al. (2021) studied the effects of shutdown on personality disorders. They found that the sense of confinement, disruption of typical routines, and reduction in social and physical interpersonal contact resulted in marked distress. Specific to AVPD, avoidance-oriented coping styles, including avoidance of behaviors and thoughts as well as drug use and denial, were found to be detrimental in managing difficult situations such as the COVID-19 pandemic.[45]
TREATMENT
Although AVPD remains moderately stable throughout a person's lifetime, treatment can be useful in mitigating its effects. AVPD has a 12-month remission rate of 31% according to the Collaborative Longitudinal Personality Disorders Study and Norwegian Twin Registry Study.[46] For example, treatment through attachment theory can prove helpful in forming a secure attachment base for the patient and bringing them confidence in the workplace.[47]
Attachment therapy, a form of psychodynamic therapy, subscribes to the need for a secure attachment and the possibility of developing earned security. Following this model, successful therapeutic interactions will rework the patient's attachment relationships through positive psychotherapeutic relationships, developing coherence (clear narrative of experiences, integrating thoughts, feelings, contexts, and meanings), collaboration (valuing relationships and positive communications), understanding and forgiveness to caretakers, and compassion towards oneself.[48] In the process of attachment therapy, it is important to both accept and challenge persistent avoidance behaviors; AVPD patients often will avoid therapy, showing up late or not at all, due to their mistrust or fear of rejection. Compassionate attachment therapy helps a patient to overcome the learned avoidant behaviors from malevolent parenting experiences and reaffirm the therapist or another relationship as a "secure base" of attachment, becoming both a "launching point" to take risks in the world and a "safe haven" for comfort.[49]
Other forms of therapy have proven to have even higher recovery rates. Cognitive Behavioral Therapy, or CBT, demonstrated a 40% recovery rate as assessed by a Fear of Negative Evaluation Questionnaire following a four-day intensive group CBT.[50] CBT can include exposure exercises, systematic desensitization, behavior rehearsal in role plays, self-image work with video feedback, and social skills training. Additionally, a more cognitive version of CBT has demonstrated a 91% recovery rate in a study of 21 patients randomized to cognitive therapy. This form of therapy involved developing individualized models of social fears, identifying dysfunctional core beliefs, and challenging avoidant "safety behaviors".[51] However, as a caveat, CBT can be difficult for patients with AVPD, as patients may be too consumed with anxiety to reduce their safety behaviors or enter the roleplay situation. Compassion and an emphasis on experimentation are important in combating this difficulty.
Schema therapy has also shown promising results with AVPD patients. Stable results at a three-year follow up showed an 80% recovery rate following schema therapy.[52] In practicing schema therapy, therapists work with patients' schema modes (momentary mid states of cognitions, emotions, and behaviors) in an integration of CBT, psychodynamic, and Gestalt techniques. Specific schema modes of AVPD that therapists often work with include the Lonely Child mode (feelings of loneliness, being unloved, unworthiness), Avoidant Protector mode (situational avoidance), Detached Protector mode (avoiding inner needs, emotions, and emotional contact), and the Punitive Parent mode (feeling that oneself deserves punishment or blame).[53] By working to understand and deconstruct these schema, therapists work with patients to build self-compassion and healthy relationships.
To learn more and read a case study involving AVPD, click here.
Contributed by: Anna Kiesewetter
Editors: Jennifer (Ghahari) Smith, Ph.D. & Brittany Canfield, Psy.D.
References
1 American Psychiatric Association. (2013). Criteria for the Personality Disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). https://www.psi.uba.ar/academica/carrerasdegrado/psicologia/sitios_catedras/practicas_profesionales/820_clinica_tr_personalidad_psicosis/material/dsm.pdf
2 Ibid.
3 Weinbrecht, A., Schulze, L., Boettcher, J., and Renneberg, B. (2016). Avoidant Personality Disorder: a Current Review. Current Psychiatry Reports, 18(29). https://doi.org/10.1007/s11920-016-0665-6.
4 Ibid.
5 Denny, B., Fan, J., Liu, X., Guerreri, S., Mayson, S., Rimsky, L., Mcmaster, A., Alexander, H., New, A., Goodman, M., Perez-Rodriguez, M., Siever, L., Koenigsberg, H. (2016). Brain structural anomalies in borderline and avoidant personality disorder patients and their associations with disorder-specific symptoms. Journal of Affective Disorders, 200, 266-274. https://doi.org/10.1016/j.jad.2016.04.053.
6 APA, 2013
7 Ibid.
8 Ibid.
9 Ibid.
10 Weinbrecht et al., 2016
11 Lampe, L., & Malhi, G. S. (2018). Avoidant personality disorder: Current insights. Psychology Research and Behavior Management, 11, Article 55-66. https://doi.org/10.2147/PRBM.S121073.
12 Ibid.
13 Ibid.
14 APA, 2013
15 Weinbrecht et al., 2016
16 Lampe & Malhi, 2018
17 Weinbrecht et al., 2016
18 Lampe & Malhi, 2018
19 Ibid.
20 Ibid.
21 Weinbrecht et al., 2016
22 Ibid.
23 Lampe & Malhi, 2018
24 Weinbrecht et al., 2016
25 Lampe & Malhi, 2018
26 Ibid.
27 Ibid.
28 Ibid.
29 Weinbrecht et al., 2016
30 Lampe & Malhi, 2018
31 Ibid.
32 Weinbrecht et al., 2016
33 Ibid.
34 Lampe & Malhi, 2018
35 Denny et al., 2016
36 Weinbrecht et al., 2016
37 Lampe & Malhi, 2018
38 Ibid.
39 Ibid.
40 Ibid.
41 Westen, D., Nakash, O., Thomas, C., and Bradley, R. (2006). Clinical assessment of attachment patterns and personality disorder in adolescents and adults. J Consult Clinical Psychology, 76(6):1065-85. doi: 10.1037/0022-006X.74.6.1065.
42 Ibid.
43 Kvarstein, E., Zahl, K., Stänicke, L., Pettersen, M., Baltzersen, A., Johansen, M., Eikenaes, I., Arnevik, E., Hummelen, B., Wilberg, T., and Pedersen, G. (2021). Vulnerability of personality disorder during the Covid-19 crises - a multicenter survey of treatment experiences among patients referred to treatment. Nordic Journal of Psychiatry, 76(1): 52-63. https://doi.org/10.1080/08039488.2021.1934110.
44 Ibid.
45 Sica, C., Latzman, R., Caudek, C., Cerea, S., Colpizzi, I., Caruso, M., Giulini, P., Bottesi, G. (2021). Facing distress in Coronavirus era: The role of maladaptive personality traits and coping strategies. Personality and Individual Differences, 177. https://doi.org/10.1016/j.paid.2021.110833.
46 Lampe & Malhi, 2018
47 Guina, 2016
48 Ibid.
49 Ibid.
50 Weinbrecht et al., 2016
51 Ibid.
52 Ibid.
53 Ibid.