Avoidant personality disorder is characterized by the avoidance of social situations or interactions that involve risk of rejection, criticism, or humiliation. Diagnosis is by clinical criteria. Treatment is with psychotherapy, anxiolytics, and antidepressants.
(See also Overview of Personality Disorders.)
People with avoidant personality disorder have intense feelings of inadequacy and cope maladaptively by avoiding any situations in which they may be evaluated negatively.
Reported prevalence of avoidant personality disorder in the United States varies, but estimated prevalence is about 2.1% (1). In community surveys, avoidant personality disorder affects females more often than males, though the difference is small (2).
Comorbidities are common. Patients often also have major depressive disorder, persistent depressive disorder, obsessive-compulsive disorder, or an anxiety disorder (eg, panic disorder, particularly social phobia [social anxiety disorder]) (3, 4 ). They may also have another personality disorder (eg, dependent personality disorder, borderline personality disorder). Patients with social phobia and avoidant personality disorder have more severe symptoms and disability than those with either disorder alone.
General references
1. Morgan TA, Zimmerman M: Epidemiology of personality disorders. In Handbook of Personality Disorders: Theory, Research, and Treatment. 2nd ed, edited by WJ Livesley, R Larstone, New York, NY: The Guilford Press, 2018, pp. 173-196.
2. Grant BF, Hasin DS, Stinson FS, et al: Prevalence, correlates, and disability of personality disorders in the United States: Results from the national epidemiologic survey on alcohol and related conditions. J Clin Psychiatry 65: 948-958, 2004. doi: 10.4088/jcp.v65n0711
3. Grant BF, Hasin DS, Stinson FS, et al: Co-occurrence of 12-month mood and anxiety disorders and personality disorders in the US: results from the national epidemiologic survey on alcohol and related conditions.J Psychiatr Res 39(1):1-9, 2005. doi: 10.1016/j.jpsychires.2004.05.004
4. Zimmerman M, Rothschild L, Chelminski I: The prevalence of DSM-IV personality disorders in psychiatric outpatients. Am J Psychiatry 162:1911-1918, 2005. doi: 10.1176/appi.ajp.162.10.1911
Etiology of Avoidant Personality Disorder
Research suggests that experiences of rejection and marginalization during childhood and innate traits of social anxiety and avoidance may contribute to avoidant personality disorder (1, 2). Avoidance in social situations has been detected as early as about age 2 years.
Etiology references
1. Joyce PR, McKenzie JM, Luty SE, et al: Temperament, childhood environment and psychopathology as risk factors for avoidant and borderline personality disorders. Aust N Z J Psychiatry 37(6):756-764, 2003. doi: 10.1080/j.1440-1614.2003.01263.x
2. Eikenaes I, Egeland J, Hummelen B, et al: Correction: Avoidant personality disorder versus social phobia: The significance of childhood neglect. PLoS One 15;10(5):e0128737, 015. doi: 10.1371/journal.pone.0128737
Symptoms and Signs of Avoidant Personality Disorder
Patients with avoidant personality disorder avoid social interaction, including those at work, because they fear that they will be criticized or rejected or that people will disapprove of them, as in the following situations:
They may refuse a promotion because they fear coworkers will criticize them.
They may avoid meetings.
They avoid making new friends unless they are sure they will be liked.
These patients assume people will be critical and disapproving until rigorous tests proving the contrary are passed. Thus, before joining a group and forming a close relationship, patients with this disorder require repeated assurances of support and uncritical acceptance.
Patients with avoidant personality disorder long for social interaction but fear placing their well-being in the hands of others. Because these patients limit their interactions with people, they are relatively isolated and do not have a social network that could help them when they need it.
These patients are very sensitive to anything slightly critical, disapproving, or mocking because they constantly think about being criticized or rejected by others. They are vigilant for any sign of a negative response to them. Their tense, anxious appearance may elicit mockery or teasing, thus seeming to confirm their self-doubts.
Low self-esteem and a sense of inadequacy inhibit these patients in social situations, especially new ones. Interactions with new people are inhibited because patients think of themselves as socially inept, unappealing, and inferior to others. They are typically quiet and timid and try to disappear because they think that if they say anything, others will say it is wrong. They are reluctant to talk about themselves lest they be mocked or humiliated. They worry they will blush or cry when criticized.
Patients with avoidant personality disorder are reluctant to take personal risks or participate in new activities for similar reasons. In such cases, they often exaggerate the dangers and use minimal symptoms or other problems to explain their avoidance. They may prefer a limited lifestyle because of their need for security and certainty.
Diagnosis of Avoidant Personality Disorder
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) criteria
For a diagnosis of avoidant personality disorder (1), patients must have
A persistent pattern of avoiding social contact, feeling inadequate, and being hypersensitive to criticism and rejection
This pattern is shown by the presence of ≥ 4 of the following:
Avoidance of job-related activities that involve interpersonal contact because they fear that they will be criticized or rejected or that people will disapprove of them
Unwillingness to get involved with people unless they are sure of being liked
Reserve in close relationships because they fear ridicule or humiliation
Preoccupation with being criticized or rejected in social situations
Inhibition in new social situations because they feel inadequate
Self-assessment as socially incompetent, unappealing, or inferior to others
Reluctance to take personal risks or participate in any new activity because they may be embarrassed
Also, symptoms must have begun by early adulthood.
Differential diagnosis
Avoidant personality disorder must be distinguished from the following 2 disorders:
Social phobia: Differences between social phobia and avoidant personality disorder are subtle. Avoidant personality disorder involves more pervasive anxiety and avoidance than social phobia, which is often specific to situations that may result in public embarrassment (eg, public speaking, performing on stage). However, social phobia may involve a broader avoidance pattern and thus may be hard to distinguish. The 2 disorders often occur together.
Schizoid personality disorder: Both disorders are characterized by social isolation. However, patients with schizoid personality disorder become isolated because they are disinterested in others, whereas those with avoidant personality disorder become isolated because they are hypersensitive to possible rejection or criticism by others.
Other personality disorders may be similar in some ways to avoidant personality disorder but can be distinguished by characteristic features (eg, by a need to be cared for in dependent personality disorder vs avoidance of rejection and criticism in avoidant personality disorder).
Diagnosis reference
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed, Text Revision (DSM-5-TR). Washington, DC, American Psychiatric Association, 2022, pp 764-768.
Treatment of Avoidant Personality Disorder
Cognitive-behavioral therapy focused on social skills
Supportive psychotherapy
Psychodynamic psychotherapy
Anxiolytics and antidepressants
General principles for treatment of avoidant personality disorder are similar to those for all personality disorders.
Patients with avoidant personality disorder often avoid treatment.
Effective therapies for patients with both social phobia and avoidant personality disorder include the following (1):
Cognitive-behavioral therapy that focuses on acquisition of social skills, done in groups
Other group therapies if the group consists of people with the same difficulties
Patients with avoidant personality disorder benefit from individual therapies that are supportive and sensitive to the patient's hypersensitivities toward others.
Psychodynamic psychotherapy, which focuses on underlying conflicts, may be helpful.
There are no placebo-controlled studies of medication.
Treatment reference
1. Weinbrecht A, Schulze L, Boettcher J, et al: Avoidant personality disorder: A current review. Curr Psychiatry Rep 18(3):29, 2016. doi: 10.1007/s11920-016-0665-6
