Avoidant Personality Disorder has been an evolving diagnosis as the DSM has changed. Current views of it place it on a scale with social anxiety, with that being a less severe version of APD. Shyness also is on this scale, though it is not a diagnosed disorder.
For children who are later diagnosed with APD, symptoms of shyness and fear of new situations and strangers begins in the early years. This shyness/fear increases, rather than decreases, with age and becomes a bigger problem during adolescence and high school. Its basis is a pervasive negative self image.
Avoidant Personality Disorder occurs in about .5% to 1.% of the general population. It accounts for about 10% of outpatients seen in mental health clinics. The occurrence is about equally frequent in males and females. (www.mentalhealth.com)
Criteria (From DSM-IV-TR)
A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
- Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection
- is unwilling to get involved with people unless certain of being liked
- shows restraint within intimate relationships because of the fear of being shamed or ridiculed
- is preoccupied with being criticized or rejected in social situations
- is inhibited in new interpersonal situations because of feelings of inadequacy
- views self as socially inept, personally unappealing, or inferior to others
- is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing
Until a stranger passes a stringent test proving the contrary, he or she is assumed to be critical and disapproving. Until this “test” is passed, a person with APD will be quiet, inhibited and “invisible” around other people because of a fear that any attention will be negative. These traits create a very small social network – generally limited to close family members – though the person desires to be social and receive affection.
Having a limited social network becomes difficult during more troubling life experiences, when a strong group of friends can provide an emotional outlet or help. A person with APD may not be self-reliant enough to manage such situations on their own, or the difficult experience may be with someone in his or her limited social network.
An important facet of this disorder is that the potential dangers of any situation – even ordinary situations – are greatly exaggerated in the person's mind.
Avoidant Personality Disorder is a self-fulfilling disorder. The person with APD, fearful of criticism and anxious about blushing/crying to criticism, projects a tense or fearful demeanor which may elicit criticism and ridicule. This confirms the doubts of the person, even though it is about how he/she is reacting and not about the person as a person.
Many individuals display avoidant personality traits. Only when these traits are inflexible, maladaptive and persisting and cause significant functional impairment or subjective distress do they constitute APD. Social anxiety diagnoses requires the symptom of panic attacks when in a fear situations, APD does not require this, but it does lead to greater isolation because of the severity of the fear and avoidance that comes with it (David C. Rettew, MD, 2000). Social Anxiety and APD may both be diagnosed in an individual.
Depression is a common overlapping diagnosis for people with APD, both through the isolation APD creates and the individual's own view of him/herself.
Anxiety is a big part of social phobia, but also plays a role in those with APD.
Other Personality Disorders
Dependent personality is a common comorbid diagnosis because once someone with APD finds a partner or friend, that person becomes the world to the APD sufferer. Paranoid, Schizoid and Schizotypal personality disorders are also possible. Borderline should also be considered if some criteria are met.
As with all personality disorders, there is no treatment to cure this diagnoses, but Cognitive Behavioral Therapy has been shown to help the person with APD to manage the symptoms.
The act of therapy – building a relationship with the therapist – can be helpful in itself. Once trust is built – a generally slow process – the relationship can be a testing ground new coping skills.
Exposure therapy can be effective in managing the the symptoms.
Also similar to some other personality disorders, the symptoms of Avoidant Personality Disorder tend to decrease with age, beginning in midlife.