Learning Objectives:
After reading this article, you should be able to:

1. Identify the key characteristics and symptoms of avoidant personality disorder (AvPD).
2. Differentiate AvPD from other similar psychiatric disorders.
3. Apply the psychotherapeutic approaches for treating AvPD.

---

“Sarah,” a 30-year-old accountant, seeks therapy because she feels isolated and struggles to open up to others. She wants to have a relationship but has an intense fear of rejection. After the first session, you are unsure if she has social anxiety disorder or avoidant personality disorder (AvPD), nor are you certain whether nailing a precise diagnosis would change your psychotherapeutic approach. 

Avoidant personality disorder (AvPD) is characterized by persistent feelings of inadequacy, fear of rejection, and avoidance of social interactions. Both AvPD and social anxiety disorder, a similar condition, involve fear of social interaction. However, AvPD encompasses deeper-seated beliefs about self-worth and an aversion to intimacy, while social anxiety disorder is more focused on specific social situations. AvPD patients also tend to be more depressed and more functionally impaired than those with social anxiety disorder (Lampe L, Australas Psychiatry 2015;23(4), 343–346).

Research on AvPD is lacking, but it is estimated to affect around 2.4% of the general population, making it one of the most prevalent personality disorders (American Psychiatric Association, 2013). There is evidence to suggest that a significant percentage of patients diagnosed with social anxiety disorder have AvPD (Lampe L and Malhi GS. Psychol Res Behav Manag 2018;11:55-66). Here, we will discuss the basics of AvPD and its treatment with psychotherapy. 

Characteristics 

• Often begins in early adulthood
• Symptoms frequently emerge during adolescence
• Affects males and females equally; may be underdiagnosed in men due to societal expectations surrounding masculinity and emotional expression

Patients with AvPD often: 

• Experience immense anxiety at the prospect of making connections, dating, and social gatherings
• Fear rejection, negative evaluation, judgment, or others finding them unlikeable (unlike patients with social anxiety disorder, who fear social circumstances in general)
• Experience anxieties resulting from a sense of inferiority and inadequacy—and belief that others are not going to like or accept them
• Desire and often long for closeness with others (unlike patients with schizoid personality disorder, which is also characterized by a lack of close, intimate relationships)

Patients with AvPD also tend to overestimate the degree to which others pay attention to them. For instance, a patient with AvPD might say: “Others must be thinking the worst about me.” “I am uninteresting and boring. Why would anyone want anything to do with me?” Or, “I know they aren’t going to text me back. I’m not even going to try.” It has been suggested that AvPD patients have significant impairments in their sense of agency due, in part, to this type of lack of emotional awareness (Weme AV et al, Front Psychol 2023;14:1248617).

Differential diagnosis and cultural considerations

AvPD must be differentiated from several other psychiatric disorders, including social anxiety disorder, schizoid personality disorder, dependent personality disorder, and autism spectrum disorder. As noted above, avoidance in AvPD patients is more intricately tied to feelings of shame and low self-worth than for social anxiety disorder patients. Compared to patients with schizoid personalities, AvPD patients much more frequently express a desire for close, intimate relationships. In dependent personality disorder, the patient tends to feel helpless and submissive, whereas AvPD patients have greater fears of rejection. Autistic patients with average or higher intelligence can become despondent about being able to develop social relationships if they cannot “mask” adequately; AvPD patients lack all of the other characteristic features of autism.

Some cultures encourage more humility, modesty (even self-deprecation), and a sense of shame than others. Patients from these cultures may not express high self-esteem or self-confidence as readily, which could make differential diagnosis more difficult. Clinicians should be attuned to these cultural differences that could lead to a pattern of behavior that looks like AvPD but is instead the result of normal cultural influence. 

Making the diagnosis

Some helpful questions to assist in the diagnosis of AvPD include:

• “How often do you avoid getting to know someone because you are worried they may not like you?”
• “In social situations, how much do you worry about being criticized or rejected by other people?”
• “Do you usually feel like you’re not as interesting or as fun as other people?”

These questions evaluate the personal beliefs underlying the avoidance behavior, which will aid in differentiating AvPD from social anxiety disorder.

Theoretical considerations

From a psychodynamic perspective, AvPD stems from early childhood experiences, particularly those involving inadequate or inconsistent caregiving (Millon T et al. Personality Disorders in Modern Life. John Wiley & Sons; 2004). Children who grow up feeling rejected or invalidated by caregivers may develop a deep-seated fear of abandonment and rejection. These experiences shape their self-perception, leading to beliefs of unworthiness and inadequacy. As a result, individuals with AvPD may resort to defenses such as withdrawal to protect themselves from feelings of shame and inferiority.

Cognitive behavior theorists emphasize the role of maladaptive thought patterns and behaviors in the development and maintenance of AvPD (Beck AT et al. Cognitive Therapy of Personality Disorders. Guilford Publications; 2015). Individuals with AvPD often hold negative beliefs about themselves and anticipate criticism or rejection in social situations. These distorted thoughts contribute to avoidance behaviors aimed at minimizing perceived threats. Over time, avoidance reinforces the belief that social interaction is dangerous, perpetuating the cycle of avoidance and isolation.

Sarah’s therapist, “Dr. Johnson,” asks her to describe how she feels in social situations. Sarah says, “I don’t feel like I have anything worthwhile to offer. Even though I have thoughts that come into my mind, I don’t share them because I think people will just find me stupid for sharing them.” When asked about her views of herself, Sarah acknowledges feeling inferior to others: not as smart, not as attractive, and not as interesting. Dr. Johnson diagnoses Sarah with AvPD. 

Treatment of AvPD

Psychotherapy is considered the treatment of choice for AvPD. While medication can be useful in the treatment of social anxiety disorder, no randomized controlled trials have been published studying the pharmacological treatment of AvPD. When it comes to therapy, both cognitive behavioral therapy (CBT) and psychodynamic therapy can be beneficial for AvPD.

Cognitive-behavioral therapy

In CBT, the therapist helps the individual identify and challenge negative thought patterns and behaviors associated with AvPD (Beck et al, 2015). Through gradual exposure and cognitive restructuring, individuals can learn healthier coping strategies and improve their social skills.

• To target patients’ fears of rejection, CBT therapists might point out common cognitive distortions, such as jumping to conclusions: “You seem to expect specific people to reject you without any evidence to support that conclusion.”
• To address feelings of inadequacy, CBT therapists might encourage patients to challenge automatic negative thoughts surrounding self-worth by taking a more comprehensive self-inventory of both assets and liabilities: “It seems that you tend to discount many of your positive attributes; perhaps we can work together to identify these to allow for a fuller and more accurate view of yourself.”
• The therapist may encourage new patterns of behavior and suggest strategies for improving social communication: “By next session, I want you to reach out to three of your old college friends to see if they would be interested in getting lunch.” 

Psychodynamic therapy

In psychodynamic therapy, the therapist explores the underlying unconscious conflicts and early childhood experiences contributing to AvPD symptoms (Millon et al, 2004). By bringing these unconscious dynamics into awareness, individuals can gain insight into their behavior and work towards resolving underlying issues. Psychodynamic therapists pay close attention to the developmental history, the patient’s internal life, and transference and countertransference issues.

A psychodynamic therapist might interpret the transference reaction to provide insight into the patient’s unconscious patterns of behavior.

For instance, a psychodynamic therapist might say, “You’ve mentioned to me a few times that you feel you are less important than my other patients, or that other patients need my help more than you do. Could this reflect the way you see yourself, and, in turn, affect the way other people see or treat you?”

Transference and countertransference

Common transference reactions in AvPD patients include mistrust or fear of being judged by the therapist (Kantor, 2013). Some patients may play out their avoidant patterns in an avoidance of therapy itself. For instance, AvPD patients may frequently arrive late, “accidentally” forget their appointment times, or routinely reschedule. An important part of treatment is to discuss these patterns as they play out in the therapy relationship itself.

Countertransference issues may involve frustration or impatience due to slow progress in treatment or perceived resistance to change. Sometimes, this leads to the therapist abandoning therapeutic neutrality and becoming more directive or instructive than appropriate. Other times, it leads to premature discharge of the patient from psychotherapy due to a sense that the patient’s condition is untreatable. Personal psychotherapy or analysis helps resolve these technical errors.

Dr. Johnson is trained in both psychodynamic therapy and CBT. He begins exploring Sarah’s early experiences with her family. Together, they discover that Sarah’s early environment was marked by a critical and invalidating relationship with her father, who would frequently compare her to her siblings and cousins. Through interpretation of the transference, Sarah gains insight into the roots of her avoidance behaviors. She realizes that her anxiety around connecting with people has to do with her negative self-perception. Dr. Johnson then draws on his CBT skills to teach Sarah specific behavioral strategies which she practices during homework assignments to reach out to several old friends. .

CARLAT VERDICT

Although AvPD is a neglected psychiatric condition, it is also quite common, and an understanding of its psychodynamics and psychotherapeutic treatment can yield clinical benefit for this subset of patients.

Key points:  Emphasize the importance of building trust and rapport with AvPD patients Encourage clinicians to be patient and nonjudgmental, as individuals with AvPD may be highly sensitive to criticism or perceived rejection Highlight the value of a gradual, step-by-step approach to therapy, allowing clients to acclimate to therapeutic settings and interventions Stress the significance of validating clients' experiences and emotions, as this can foster a sense of safety and acceptance Address both presenting symptoms and understand the psychodynamic history, as both can be important components of effective treatment for AvPD

References in the order of appearance in this article 

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Beck, A. T., Freeman, A., & Davis, D. D. (2015). Cognitive therapy of personality disorders. Guilford Publications.

Kantor, M. (2013). Understanding transference: The Core Conflictual Relationship Theme Method (2nd ed.). Routledge.

Lampe L. (2015). Social anxiety disorders in clinical practice: differentiating social phobia from avoidant personality disorder. Australasian psychiatry : bulletin of Royal Australian and New Zealand College of Psychiatrists, 23(4), 343–346. https://doi.org/10.1177/1039856215592319

Lampe L, Malhi GS. Avoidant personality disorder: current insights. Psychol Res Behav Manag. 2018;11:55-66. Published 2018 Mar 8. doi:10.2147/PRBM.S121073

Millon, T., Grossman, S., Millon, C., Meagher, S., & Ramnath, R. (2004). Personality disorders in modern life. John Wiley & Sons.

Weme AV, Sørensen KD, Binder PE. Agency in avoidant personality disorder: a narrative review. Front Psychol. 2023;14:1248617. Published 2023 Sep 18. doi:10.3389/fpsyg.2023.1248617