Avoidant Personality Disorder

From Wikipedia, the free encyclopedia
Not to be confused with Antisocial personality disorder.
Avoidant personality disorder
Classification and external resources
ICD10 F60.6
ICD9 301.82
MedlinePlus 000940
eMedicine ped/189
MeSH D010554
Cluster A (odd)
Paranoid Schizoid
Cluster B (dramatic)
Antisocial Borderline
Histrionic Narcissistic
Cluster C (anxious)
Avoidant Dependent
Not specified
Sadistic Self-defeating
v d· e

Avoidant personality disorder[1] (or anxious personality disorder)[2] is a personality disorder recognized in the Diagnostic and Statistical Manual of Mental Disorders handbook in a person characterized by a pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation, and avoidance of social interaction.

People with avoidant personality disorder often consider themselves to be socially inept or personally unappealing and avoid social interaction for fear of being ridiculed, humiliated, rejected, or disliked. Avoidant personality disorder is usually first noticed in early adulthood. Childhood emotional neglect and peer group rejection (e.g. bullying) are both associated with an increased risk for the development of AvPD.

There is controversy as to whether avoidant personality disorder is a distinct disorder from generalized social phobia and it is contended by some that they are merely different conceptualizations of the same disorder, where avoidant personality disorder may represent the more severe form.[3][4] This is argued as generalized social phobia and avoidant personality disorder have a similar diagnostic criteria and may share a similar causation, subjective experience, course, treatment, and identical underlying personality features, such as shyness.[5][6][7]



The avoidant personality has been described in several sources as far back as the early 1900s, although it was not so named for some time. Swiss psychiatrist Eugen Bleulerdescribed patients who exhibited signs of avoidant personality disorder in his 1911 work Dementia Praecox: Or the Group of Schizophrenias.[8] Avoidant and schizoid patterns were frequently confused or referred to synonymously until Kretschmer (1921),[9] in providing the first relatively complete description, developed a distinction.


Signs and symptoms


People with avoidant personality disorder are preoccupied with their own shortcomings and form relationships with others only if they believe they will not be rejected. Loss and rejection are so painful that these individuals will choose to be lonely rather than risk trying to connect with others.





Apart from the above, other causes of avoidant personality disorder are not clearly defined, and may be influenced by a combination of social, genetic, and psychological factors. The disorder may be related to temperamental factors that are inherited.[13][14] Specifically, various anxiety disorders in childhood and adolescence have been associated with a temperament characterized by behavioral inhibition, including features of being shy, fearful, and withdrawn in new situations.[15] These inherited characteristics may give an individual agenetic predisposition towards AvPD.[16]Childhood emotional neglect[17][18][19][20] and peer group rejection[11] are both associated with an increased risk for the development of AvPD.[13]




World Health Organization


The World Health Organization‘s ICD-10 lists avoidant personality disorder as (F60.6) anxious (avoidant) personality disorder.[2] It is characterized by at least four of the following:[21]


  1. persistent and pervasive feelings of tension and apprehension;
  2. belief that one is socially inept, personally unappealing, or inferior to others;
  3. excessive preoccupation with being criticized or rejected in social situations;
  4. unwillingness to become involved with people unless certain of being liked;
  5. restrictions in lifestyle because of need to have physical security;
  6. avoidance of social or occupational activities that involve significant interpersonal contact because of fear of criticism, disapproval, or rejection.


Associated features may include hypersensitivity to rejection and criticism.


It is a requirement of ICD-10 that a diagnosis of any specific personality disorder also satisfy a set of general personality disorder criteria.


Millon’s subtypes


Psychologist  Theodore Millon identified four subtypes of avoidant personality disorder.[22][23]  Any individual avoidant may exhibit none or one of the following:


  • conflicted avoidant – including negativistic features


The conflicted avoidant feels ambivalent towards themselves and others. They can idealize those close to them but under stress they may feel under-appreciated or misunderstood and wish to hurt others in revenge.[22] They may be perceived as petulant or to be sulking.[22]


  • hypersensitive avoidant – including paranoid features


The hypersensitive avoidant experiences paranoia, mistrustfulness and fear, but to a lesser extent than an individual with paranoid personality disorder.[22] They may be perceived as petulant or “high-strung“.[23]


  • phobic avoidant – including dependent features


  • self-deserting avoidant – including depressive features


Differential diagnosis


Research suggests that people with avoidant personality disorder, in common with sufferers of chronic social anxiety disorder (also called social phobia), excessively monitor their own internal reactions when they are involved in social interaction. However, unlike social phobics, who are aware of the irrationality of their phobia yet are unable to control it, people with avoidant personality disorder are unaware of or reject the idea that their fears are excessive and believe with full conviction that they are inadequate, un-lovable, broken, etc.


The extreme tension created by this monitoring may account for the hesitant speech and taciturnity of many people with avoidant personality disorder; they are so preoccupied with monitoring themselves and others that producing fluent speech is difficult.


Avoidant personality disorder is reported to be especially prevalent in people with anxiety disorders, although estimates of co-morbidity vary widely due to differences in (among others) diagnostic instruments. Research suggests that approximately 10-50% of people who have panic disorder with agoraphobia have avoidant personality disorder, as well as about 20-40% of people who have social phobia (social anxiety disorder).


Some studies report prevalence rates of up to 45% among people with generalized anxiety disorder and up to 56% of those with obsessive-compulsive disorder.[24] Although it is not mentioned in the DSM-IV, earlier theorists have proposed a personality disorder which has a combination of features from borderline personality disorder and avoidant personality disorder, called “avoidant-borderline mixed personality” (AvPD/BPD).[25]


There is also significant overlap between avoidant personality disorder and autism spectrum disorders.[citation needed]




Treatment of avoidant personality disorder can employ various techniques, such as social skills trainingcognitive therapy, exposure treatment to gradually increase social contacts,group therapy for practicing social skills, and sometimes drug therapy.[26]  A key issue in treatment is gaining and keeping the patient’s trust, since people with avoidant personality disorder will often start to avoid treatment sessions if they distrust the therapist or fear rejection. The primary purpose of both individual therapy and social skills group training is for individuals with avoidant personality disorder to begin challenging their exaggerated negative beliefs about themselves.[27]


However, because of the deep-seated feelings of inferiority and extreme social fear, it is unlikely that those with AvPD will ever overcome the disorder entirely, with the prognosis being even worse for those low-functioning persons as they are likely to drop out of treatment if they become too anxious. [28]




According to the DSM-IV-TR, avoidant personality disorder occurs in approximately 0.5% to 1% of the general population.[29] However, data from the 2001-02 National Epidemiologic survey on Alcohol and Related Conditions indicates a prevalence rate of the disorder of 2.36% in the American general population.[30] It is seen in about 10% of psychiatric outpatients.[31]


See also






  1.  Avoidant personality disorder – Diagnostic and Statistical Manual of Mental Disorders Fourth edition Text Revision (DSM-IV-TR) American Psychiatric Association (2000)
  2.  a b Avoidant personality disorder – International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10)
  3. Reich, James (2009). “Avoidant personality disorder and its relationship to social phobia”. Current Psychiatry Reports 11 (1): 89-93. doi:10.1007/s11920-009-0014-0PMID 19187715.
  4.  Huppert, Jonathan D.; Strunk, Daniel R.; Ledley, Deborah Roth; Davidson, Jonathan R. T.; Foa, Edna B. (2008). “Generalized social anxiety disorder and avoidant personality disorder: structural analysis and treatment outcome”. Depression and Anxiety 25 (5): 441-8. doi:10.1002/da.20349PMID 17618526.
  5. Ralevski, E.; Sanislow, C. A.; Grilo, C. M.; Skodol, A. E.; Gunderson, J. G.; Tracie Shea, M.; Yen, S.; Bender, D. S. et al. (2005). “Avoidant personality disorder and social phobia: distinct enough to be separate disorders?”.  Acta Psychiatrica Scandinavica 112 (3): 208-14. doi:10.1111/j.1600-0447.2005.00580.xPMID 16095476.
  6. Nedic, Aleksandra; Zivanovic, Olga; Lisulov, Ratomir (2011). “Nosological status of social phobia: contrasting classical and recent literature”. Current Opinion in Psychiatry 24 (1): 61-6. doi:10.1097/YCO.0b013e32833fb5a6PMID 20966756.
  7. Reichborn-Kjennerud, T.; Czajkowski, N.; Torgersen, S.; Neale, M. C.; Orstavik, R. E.; Tambs, K.; Kendler, K. S. (2007). “The Relationship Between Avoidant Personality Disorder and Social Phobia: A Population-Based Twin Study”.  American Journal of Psychiatry 164(11): 1722-8.  doi:10.1176/appi.ajp.2007.06101764PMID 17974938.
  8. Millon, Theodore; Martinez, Alexandra (1995). “Avoidant Personality Disorder”. In Livesley, W. John. The DSM-IV Personality DisordersGuilford Press. pp. 218.ISBN 0898622573.
  9. Kretschmer, Ernst (1921). KÃrperbau und Charakter. J. Springer.
  10. “Avoidant personality disorder”.  Avoidant personality disorder. Healthline Networks. 2003. Retrieved 2006-02-26.
  11. a b Sperry, Len (2003).  “Avoidant Personality Disorder”.  Handbook of diagnosis and treatment of DSM-IV-TR personality disorders. Philadelphia: Brunner-Routledge. pp. 59-79. ISBN  978-0-415-93569-2.
  12. Avoidant Personality Disorder, Real Mental Health, Inc.
  13. a b Eggum, Natalie D.; Eisenberg, Nancy; Spinrad, Tracy L.; Valiente, Carlos; Edwards, Alison; Kupfer, Anne S.; Reiser, Mark (2009). “Predictors of withdrawal: Possible precursors of avoidant personality disorder”.  Development and Psychopathology  21 (3): 815-38.  doi:10.1017/S0954579409000443PMC  2774890.  PMID  19583885.
  14. Rettew, David C.; Michael S Jellinek, Alicia C Doyle (March 4, 2008). “Avoidant Personality Disorder”eMedicine. Retrieved January 26, 2010.
  15. “Avoidant Personality Disorder Causes, Frequency, Siblings and Mortality Morbidity”.  Avoidant Personality Disorder. Armenian Medical Network. 2006. Retrieved 2007-02-26.
  16. Lenzenweger, Mark F.; Clarkin, John F. (2005). Major Theories of Personality DisorderGuilford Press. p. 69. ISBN  1-59385-108-1.
  17. Johnson, JG; Smailes, EM; Cohen, P; Brown, J; Bernstein, DP (2000). “Associations between four types of childhood neglect and personality disorder symptoms during adolescence and early adulthood: findings of a community-based longitudinal study”. Journal of personality disorders 14 (2): 171-87. PMID 10897467.
  18. Joyce, Peter R.; McKenzie, Janice M.; Luty, Suzanne E.; Mulder, Roger T.; Carter, Janet D.; Sullivan, Patrick F.; Cloninger, C. Robert (2003). “Temperament, childhood environment and psychopathology as risk factors for avoidant and borderline personality disorders”.Australian and New Zealand Journal of Psychiatry 37 (6): 756-64.  doi:10.1111/j.1440-1614.2003.01263.xPMID 14636393.
  19. Johnson, J. G.; Cohen, P; Brown, J; Smailes, EM; Bernstein, DP (1999). “Childhood Maltreatment Increases Risk for Personality Disorders During Early Adulthood”.  Archives of General Psychiatry 56 (7): 600-6.  doi:10.1001/archpsyc.56.7.600.  PMID  10401504.
  20. Battle, Cynthia L.; Shea, M. Tracie; Johnson, Dawn M.; Yen, Shirley; Zlotnick, Caron; Zanarini, Mary C.; Sanislow, Charles A.; Skodol, Andrew E. et al. (2004). “Childhood Maltreatment Associated With Adult Personality Disorders: Findings From the Collaborative Longitudinal Personality Disorders Study”.  Journal of Personality Disorders 18 (2): 193-211.  doi:10.1521/pedi. 15176757.
  21. WHO.int
  22. a b c d Millon, Theodore; Carrie M. Millon, Seth Grossman, Sarah Meagher, Rowena Ramnath (2004).  Personality Disorders in Modern LifeJohn Wiley and Sons. pp. 194.ISBN 0-471-23734-5.
  23. a b Millon, Theodore (2006). “Personality Subtypes Summary”.  The Official Website for Theodore Millon, Ph.D., D.Sc.. DICANDRIEN, Inc. Retrieved January 23, 2010.
  24. Van Velzen, C. J. M. (2002).  Social phobia and personality disorders: Co-morbidity and treatment issues. Groningen: University Library Groningen. (online version)
  25. Kantor, M. (1993, revised 2003). Distancing: A guide to avoidance and avoidant personality disorder. Westport, Conn: Praeger Publishers.
  26. Comer, R. J. (1996). Fundamentals of abnormal psychology. Avoidant personality disorder, pp.428-430. Third edition. New York: Worth.
  27. Eckleberry, Sharon C. (2000-03-25).  “Dual Diagnosis and the Avoidant Personality Disorder”The Dual Diagnosis Pages: From Our Desk. Archived from the original on 2006-12-16. Retrieved 2007-02-06.
  28. “Avoidant personality disorder”.  Healthline Networks. 2003.. Retrieved 25 October 2011.
  29. Webb, James T.; Amend, Edward R.; Webb, Nadia (2005).  “Ideational and Anxiety Disorders”.  Misdiagnosis and dual diagnoses of gifted children and adults: Attention Deficit Hyperactivity Disorder, bipolar, Obsessive Compulsive Disorder, Asperger’s, depression, and other disorders. Great Potential Press, Inc. pp. 112.  ISBN  0-910707-67-7.
  30. Grant, Bridget F.; Hasin, Deborah S.; Stinson, Frederick S.; Dawson, Deborah A.; Chou, S. Patricia; Ruan, W. June; Pickering, Roger P. (2004). “Prevalence, Correlates, and Disability of Personality Disorders in the United States”.  The Journal of Clinical Psychiatry65 (7): 948-58.  doi:10.4088/JCP.v65n0711.  PMID 15291684.
  31. Internet Mental Health – avoidant personality disorder



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