Avoidant personality disorder

{{Short description|Personality disorder}} {{cs1 config|name-list-style=vanc|display-authors=6}} {{Infobox medical condition (new) | image = Loneliness in a Crowd.jpg | alt = Artwork showing a lonely woman in the midst of a crowd | caption = [[Social inhibition]] is common in AvPD | name = Avoidant personality disorder | synonyms = Anxious personality disorder | field = [[Psychiatry]], [[clinical psychology]] | symptoms = [[Social anxiety]], [[social inhibition]], feelings of inadequacy and [[Inferiority complex|inferiority]], [[social withdrawal|withdrawal]] | complications = [[Substance use disorder]]s, [[self-harm]], [[Major Depressive Disorder]] | duration = Chronic / Lifelong | risks = [[Child neglect|Childhood emotional neglect]], [[genetic predisposition]], repeated [[peer rejection]] in childhood, repeated childhood [[bullying]] | differential = [[Social anxiety disorder]], [[schizoid personality disorder]], [[schizotypal personality disorder]], [[autism spectrum disorder]] | treatment = [[Psychotherapy]] }}{{Personality disorders sidebar}} '''Avoidant personality disorder''' ('''AvPD''')<noinclude>, or '''anxious personality disorder''',</noinclude> is <noinclude>a [[personality disorder]] </noinclude>characterized by excessive [[social anxiety]] and [[Social inhibition|inhibition]], [[fear of intimacy]] (despite an intense desire for it), severe feelings of inadequacy and [[Inferiority complex|inferiority]], and an overreliance on [[Avoidance coping|avoidance of feared stimuli]] (e.g., self-imposed [[social isolation]]) as a maladaptive [[Coping (psychology)|coping method]].<ref name="who.int">''Anxious [avoidant personality disorder]'' in ICD-10: [https://www.who.int/classifications/icd/en/GRNBOOK.pdf#155 Diagnostic Criteria] {{Webarchive|url=https://web.archive.org/web/20160618131606/http://www.who.int/classifications/icd/en/GRNBOOK.pdf#155|date=2016-06-18}} and [https://www.who.int/classifications/icd/en/bluebook.pdf#161 Clinical descriptions and guidelines.] {{Webarchive|url=https://web.archive.org/web/20140323025330/http://www.who.int/classifications/icd/en/bluebook.pdf#161|date=2014-03-23}}</ref> Those affected typically display a pattern of [[Fear of negative evaluation|extreme sensitivity to negative evaluation]] and [[Social rejection|rejection]], a belief that one is socially inept or personally unappealing to others, and avoidance of [[Interpersonal relationship|social interaction]] despite a strong desire for it.<ref name=":11" /><noinclude> It appears to affect an approximately equal number of men and women.<ref name=":11" /></noinclude>

People with AvPD often avoid social interaction for fear of being [[Mockery|ridiculed]], [[Humiliation|humiliated]], [[social rejection|rejected]], or disliked. They typically avoid becoming involved with others unless they are certain they will not be rejected, and may also pre-emptively abandon relationships due to [[fear]] of a real or imagined risk of being rejected by the other party.<ref name=":5" />

[[Child neglect|Childhood emotional neglect]] (in particular, the rejection of a [[child]] by one or both [[parent]]s) and [[peer group]] rejection are associated with an increased risk for its development. However, it is possible for AvPD to occur without any history of [[abuse]] or [[neglect]].<ref name="avpd-env">{{cite web|title=Avoidant Personality Disorder – Environmental Factors|url=http://www.tljones.co.uk/apd/envmnt.htm|access-date=2013-07-22|archive-url=https://web.archive.org/web/20141028110658/http://www.tljones.co.uk/apd/envmnt.htm|archive-date=2014-10-28|url-status=dead}}</ref>

==Signs and symptoms== Avoidant individuals are preoccupied with their own shortcomings and form relationships with others only if they believe they will not be rejected. They often view themselves with contempt, while showing a decreased ability to identify traits within themselves that are generally considered as positive within their societies.<ref name="retzlaff">Will, Retzlaff, ed. (1995). p. 97</ref> Extreme [[shyness]] or [[social anxiety|anxiety]] may occur in social situations.<ref name=":11" />

Some with this disorder fantasize about idealized, accepting, and affectionate relationships because of their desire to belong. They often feel themselves unworthy of the relationships they desire, and shame themselves from ever attempting to begin them. If they do manage to form relationships, it is also common for them to pre-emptively abandon them out of fear of the relationship failing.<ref name=":5">{{cite book|last1=Hoeksema|first1=Nolen|title=Abnormal Psychology|date=2014|publisher=McGraw Education|isbn=978-1-308-21150-3|page=275|edition=6th}}</ref>

Individuals with the disorder tend to describe themselves as uneasy, anxious, lonely, unwanted and isolated from others.<ref name="millon1996">{{cite book|title=Disorders of Personality: DSM-IV and Beyond, 2nd Edition|last1=Millon|first1=Theodore|last2=Davis|first2=Roger D.|year=1996|pages=263|author-link1=Theodore Millon}}</ref> They often choose jobs of isolation in which they do not have to interact with others regularly.<ref name=":9" /> Avoidant individuals also avoid performing activities in public spaces for fear of embarrassing themselves in front of others.

==Causes== Causes of AvPD are not clearly defined,<ref name="Sed2009">{{cite book|url=https://books.google.com/books?id=7_7-5dQIpBQC&pg=PA29|title=Blueprints psychiatry|date=2009|publisher=Wolters Kluwer/Lippincott Williams & Wilkins|isbn=978-0-7817-8253-1|edition=5th|location=Philadelphia|page=29|last1=Sederer|first1=Lloyd I.}}</ref> but appear to be influenced by a combination of social, genetic and psychological factors. The disorder may be related to [[temperament]]al factors that are inherited.<ref name="eggum" /><ref name=emedicine>{{Cite web |last=Rettew|first=David C.|author2=Michael S Jellinek |author3=Alicia C Doyle |title=Avoidant Personality Disorder|publisher=[[eMedicine]]|date=March 4, 2008|url=http://emedicine.medscape.com/article/913360-overview|access-date=January 26, 2010|archive-url=https://web.archive.org/web/20100212013103/http://emedicine.medscape.com/article/913360-overview|archive-date=12 February 2010 |url-status=live}} </ref>

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.<ref name="amn">{{cite web|title=Avoidant Personality Disorder Causes, Frequency, Siblings and Mortality — Morbidity|publisher=Armenian Medical Network|work=Avoidant Personality Disorder|url=http://www.health.am/psy/avoidant-personality-disorder-causes/|year=2006|access-date=2007-02-26|author=Suzanne M. Sutherland, M.D.|archive-url=https://web.archive.org/web/20070930181339/http://www.health.am/psy/avoidant-personality-disorder-causes/|archive-date=2007-09-30|url-status=live}}</ref> These inherited characteristics may give an individual a [[genetic predisposition]] towards AvPD.<ref>{{cite book|last1=Lenzenweger|first1=Mark F.|first2=John F.|last2=Clarkin|title=Major Theories of Personality Disorder|publisher=[[Guilford Press]]|year=2005|page=69|url=https://books.google.com/books?id=Ht8wJUfrSNMC&pg=RA1-PA68|isbn=978-1-59385-108-8}}</ref>

Childhood emotional neglect<ref>{{cite journal|last1=Johnson|first1=JG|last2=Smailes|first2=EM|last3=Cohen|first3=P|last4=Brown|first4=J|last5=Bernstein|first5=DP|title=Associations between four types of childhood neglect and personality disorder symptoms during adolescence and early adulthood: findings of a community-based longitudinal study|journal=Journal of Personality Disorders|volume=14|issue=2|pages=171–87|year=2000|pmid=10897467|doi=10.1521/pedi.2000.14.2.171}}</ref><ref>{{cite journal|last1=Joyce|first1=Peter R.|last2=McKenzie|first2=Janice M.|last3=Luty|first3=Suzanne E.|last4=Mulder|first4=Roger T.|last5=Carter|first5=Janet D.|last6=Sullivan|first6=Patrick F.|last7=Cloninger|first7=C. Robert|title=Temperament, childhood environment and psychopathology as risk factors for avoidant and borderline personality disorders|journal=Australian and New Zealand Journal of Psychiatry|volume=37|issue=6|pages=756–64|year=2003|pmid=14636393|doi=10.1080/j.1440-1614.2003.01263.x|s2cid=154962 }}</ref><ref>{{cite journal|last1=Johnson|first1=J. G.|last2=Cohen|first2=P|last3=Brown|first3=J|last4=Smailes|first4=EM|last5=Bernstein|first5=DP|title=Childhood Maltreatment Increases Risk for Personality Disorders During Early Adulthood|journal=Archives of General Psychiatry|volume=56|issue=7|pages=600–6|year=1999|pmid=10401504|doi=10.1001/archpsyc.56.7.600|doi-access=free}}</ref><ref>{{cite journal|last1=Battle|first1=Cynthia L.|last2=Shea|first2=M. Tracie|last3=Johnson|first3=Dawn M.|last4=Yen|first4=Shirley|last5=Zlotnick|first5=Caron|last6=Zanarini|first6=Mary C.|last7=Sanislow|first7=Charles A.|last8=Skodol|first8=Andrew E.|author8-link=Andrew E. Skodol|last9=Gunderson|first9=John G.|last10=Grilo|first10=Carlos M.|last11=McGlashan|first11=Thomas H.|last12=Morey|first12=Leslie C.|title=Childhood Maltreatment Associated With Adult Personality Disorders: Findings From the Collaborative Longitudinal Personality Disorders Study|journal=Journal of Personality Disorders|volume=18|issue=2|pages=193–211|year=2004|pmid=15176757|doi=10.1521/pedi.18.2.193.32777|url=https://wesscholar.wesleyan.edu/div3facpubs/393}}</ref> and peer group rejection<ref name="sperry">{{cite book|first1=Len|last1=Sperry|chapter=Avoidant Personality Disorder|chapter-url=https://books.google.com/books?id=35VhnOG6vCcC&pg=PA59|title=Handbook of diagnosis and treatment of DSM-IV-TR personality disorders|publisher=Brunner-Routledge|location=Philadelphia|year=2003|pages=59–79|isbn=978-0-415-93569-2}}</ref> are both associated with an increased risk for the development of AvPD.<ref name="eggum">{{cite journal|last1=Eggum|first1=Natalie D.|last2=Eisenberg|first2=Nancy|last3=Spinrad|first3=Tracy L.|last4=Valiente|first4=Carlos|last5=Edwards|first5=Alison|last6=Kupfer|first6=Anne S.|last7=Reiser|first7=Mark|title=Predictors of withdrawal: Possible precursors of avoidant personality disorder|journal=Development and Psychopathology|volume=21|issue=3|pages=815–38|year=2009|pmid=19583885|pmc=2774890|doi=10.1017/S0954579409000443}}</ref> Some researchers believe a combination of [[sensory processing sensitivity|high-sensory-processing sensitivity]] coupled with adverse childhood experiences may heighten the risk of an individual developing AvPD.<ref name=":4">{{Cite journal|last1=Meyer|first1=Björn|last2=Ajchenbrenner|first2=Muriel|last3=Bowles|first3=David P.|date=December 2005|title=Sensory sensitivity, attachment experiences, and rejection responses among adults with borderline and avoidant features|journal=Journal of Personality Disorders|volume=19|issue=6|pages=641–658|doi=10.1521/pedi.2005.19.6.641|issn=0885-579X|pmid=16553560}}</ref>

==Diagnosis==

=== Classification === [[Classification of personality disorders]] differs significantly between the two most prominent frameworks for [[classification of mental disorders]], namely: the ''[[Diagnostic and Statistical Manual of Mental Disorders]]'' and the [[International Classification of Diseases]], the most recent editions of which are the [[DSM-5-TR]] and [[ICD-11]], respectively. While personality disorders, including AvPD, are diagnosed as separate entities in the DSM-5; in the [[ICD-11 classification of personality disorders]], they are assessed in terms of severity levels, with trait and pattern specifiers serving to characterize the particular style of pathology.<ref name=":72">{{Cite journal |last=Clark |first=Lee Anna |author-link=Lee Anna Clark |date=2025-05-01 |title=Wherefrom and Whither PD? Recent Developments and Future Possibilities in DSM-5 and ICD-11 Personality Disorder Diagnosis |url=https://doi.org/10.1007/s11920-025-01602-y |journal=Current Psychiatry Reports |language=en |volume=27 |issue=5 |pages=267–277 |doi=10.1007/s11920-025-01602-y |issn=1535-1645 |pmc=12003573 |pmid=40108080}} {{Creative Commons text attribution notice|cc=by4|from this source=yes}}</ref> There is also a hybrid model,<ref name=":7">{{Cite journal |last1=Rodriguez-Seijas |first1=Craig |last2=Ruggero |first2=Camilo |last3=Eaton |first3=Nicholas R. |last4=Krueger |first4=Robert F. |date=2019 |title=The DSM-5 Alternative Model for Personality Disorders and Clinical Treatment: a Review |url=https://link.springer.com/10.1007/s40501-019-00187-7 |journal=Current Treatment Options in Psychiatry |language=en |volume=6 |issue=4 |pages=284–298 |doi=10.1007/s40501-019-00187-7 |issn=2196-3061|url-access=subscription }}</ref> called the ''[[Alternative DSM-5 model for personality disorders]]'' (AMPD), which defines AvPD and five other PDs through disorder-specific combinations of pathological traits and areas of overall impairment.<ref name=":72" />

==== DSM ==== {{Further|Classification of personality disorders#DSM-5|Alternative DSM-5 model for personality disorders}} The ''DSM-5'' includes two distinct diagnostic models for personality disorder (PD). Its main body (Section II) retains a traditional, categorical model of 10 putatively distinct PDs,<ref name=":72" /> grouped into three clusters. Placed within [[cluster C]],<ref>{{Cite journal |last=Schulte Holthausen |first=Barbara |last2=Habel |first2=Ute |date=2018-10-11 |title=Sex Differences in Personality Disorders |url=https://doi.org/10.1007/s11920-018-0975-y |journal=Current Psychiatry Reports |language=en |volume=20 |issue=12 |pages=107 |doi=10.1007/s11920-018-0975-y |issn=1535-1645|url-access=subscription }}</ref> AvPD is described as "[a] pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation", [[operationalized]] through seven criteria, at least four of which must be met.<ref name=":11">{{Cite book |title=Diagnostic and Statistical Manual of Mental Disorders |title-link=Diagnostic and Statistical Manual of Mental Disorders |date=2013 |publisher=[[American Psychiatric Association]] |isbn=978-0-89042-554-1 |edition=5th |location=Washington, D.C |pages=672–675}}</ref> This system of classification has several limitations, such as each category capturing a [[heterogeneous]] set of presentations.<ref name=":7" />

With the intent to mitigate such issues and to create a system of classification with better empirical support, the AMPD was created.<ref name=":7" /> Contained within [[DSM-5#Section III: Emerging measures and models|Section III]] of both the DSM-5 and [[DSM-5-TR]] as an alternative to the categorical model,<ref name=":72" /> it defines six specific personality disorders – one of them being AvPD<ref>{{Cite journal |last1=Fowler |first1=J. Christopher |last2=Sharp |first2=Carla |last3=Kalpakci |first3=Allison |last4=Madan |first4=Alok |last5=Clapp |first5=Joshua |last6=Allen |first6=Jon G. |last7=Frueh |first7=B. Christopher |last8=Oldham |first8=John M. |date=January 1, 2015 |title=A dimensional approach to assessing personality functioning: examining personality trait domains utilizing DSM-IV personality disorder criteria |url=https://www.sciencedirect.com/science/article/pii/S0010440X14002521 |journal=Comprehensive Psychiatry |volume=56 |pages=75–84 |doi=10.1016/j.comppsych.2014.09.001 |issn=0010-440X |pmid=25261890 |url-access=subscription |quote=The number of specific PDs was reduced from 10 to 6 (antisocial, avoidant, borderline, narcissistic, obsessive–compulsive, and schizotypal) as well as a diagnosis of "personality disorder—trait specified" that can be made when criteria for a specific disorder are not met, but a personality disorder is assessed as present [23].}}</ref> – in terms of a description of the disorder; the characteristic manner in which the disorder impacts personality functioning, i.e. identity, self-direction, empathy and intimacy (criterion A); as well as a listing and description of the pathological [[personality traits]] associated with the disorder (criterion B).<ref>{{Cite journal |last1=Zimmermann |first1=Johannes |last2=Kerber |first2=André |last3=Rek |first3=Katharina |last4=Hopwood |first4=Christopher J. |last5=Krueger |first5=Robert F. |date=2019-08-13 |title=A Brief but Comprehensive Review of Research on the Alternative DSM-5 Model for Personality Disorders |url=https://doi.org/10.1007/s11920-019-1079-z |journal=Current Psychiatry Reports |volume=21 |issue=9 |pages=92 |doi=10.1007/s11920-019-1079-z |issn=1535-1645 |pmid=31410586 |url-access=subscription|doi-access=free }}</ref>

At least two of the elements of personality functioning must have a "moderate or greater impairment",<ref name=":6">{{Cite book |title=Diagnostic and Statistical Manual of Mental Disorders |title-link=Diagnostic and Statistical Manual of Mental Disorders |date=2013 |publisher=[[American psychiatric association]] |isbn=978-0-89042-554-1 |edition=5th |location=Washington |pages=765–766 |chapter=Alternative DSM-5 Model for Personality disorders}}</ref> manifesting in, for example, the following being true for the identity domain: "[l]ow self-esteem associated with self-appraisal as socially inept, personally unappealing, or inferior; excessive feelings of shame".<ref name=":72" /> The AMPD lists the following four pathological traits: [[anxiousness]], [[Social withdrawal|withdrawal]], [[anhedonia]], and intimacy avoidance;<ref name=":13" /> each of these is followed by a description of how the trait manifests in AvPD,<ref name=":6" /> such as "reticence in social situations; avoidance of social contacts and activity; [and] lack of initiation of social contact" in the case of withdrawal.<ref name=":72" /> A diagnosis requires that three of these traits are present in the subject, with anxiousness being required.<ref name=":6" /> Furthermore, additional traits can be added as specifiers to the diagnosis.<ref name=":72" /> Further requirements, for example relating to [[differential diagnosis]], are embodied in criteria C–G.<ref name=":7" />

==== ICD ==== {{Further|ICD-11 classification of personality disorders|Classification of personality disorders#ICD-10}}The [[World Health Organization]]'s [[ICD-11]] has replaced the categorical classification of personality disorders in the [[ICD-10]], in which ''anxious (avoidant) personality disorder'' ({{ICD10|F|60|6|f|60}}) was included as a distinct category,<ref name="who.int" /> with a [[Dimensional models of personality disorders|dimensional model]] containing a unified ''personality disorder'' ({{ICD11|6D10}}) with severity specifiers, along with specifiers for ''[[prominent personality traits or patterns]]'' ({{ICD11|6D11}}).<ref name=":10">{{Cite journal |last1=Bach |first1=Bo |last2=First |first2=Michael B. |date=2018-10-29 |title=Application of the ICD-11 classification of personality disorders |journal=BMC Psychiatry |volume=18 |issue=1 |pages=351 |doi=10.1186/s12888-018-1908-3 |issn=1471-244X |pmc=6206910 |pmid=30373564 |doi-access=free}}</ref> Severity is assessed based on the pervasiveness of impairment in several areas of functioning, as well as on the level of distress and harm caused by the disorder,<ref>{{Cite journal |last=Swales |first=Michaela A. |date=2022-12-15 |title=Personality Disorder Diagnoses in ICD-11: Transforming Conceptualisations and Practice |url=https://cpe.psychopen.eu/index.php/cpe/article/view/9635 |journal=Clinical Psychology in Europe |language=en |volume=4 |issue=Spec Issue |article-number=e9635 |doi=10.32872/cpe.9635 |pmid=36760321 |issn=2625-3410 |pmc=9881116}}</ref> while trait and pattern specifiers are used for recording the manner in which the disturbance is manifested.<ref name=":9">{{Cite journal |last1=Bach |first1=Bo |last2=Kramer |first2=Ueli |last3=Doering |first3=Stephan |last4=di Giacomo |first4=Ester |last5=Hutsebaut |first5=Joost |last6=Kaera |first6=Andres |last7=De Panfilis |first7=Chiara |last8=Schmahl |first8=Christian |last9=Swales |first9=Michaela |last10=Taubner |first10=Svenja |last11=Renneberg |first11=Babette |date=2022-04-01 |title=The ICD-11 classification of personality disorders: a European perspective on challenges and opportunities |journal=Borderline Personality Disorder and Emotion Dysregulation |volume=9 |issue=1 |pages=12 |doi=10.1186/s40479-022-00182-0 |doi-access=free |pmid=35361271 |issn=2051-6673 |pmc=8973542}}</ref>[[File:12888 2018 1908 Fig2.png|thumb|398x398px|This ICD-11 case profile could belong to a person eligible for ICD-10 avoidant and [[Dependent personality disorder|dependent]] PD diagnoses.<ref name=":10" />]] Anxious (avoidant) personality disorder has been found to be consistently associated with the ICD-11 trait domains ''[[Negative affectivity in personality disorder or personality difficulty|Negative Affectivity]]'' ({{ICD11|6D11.0}}) and ''[[Detachment in personality disorder or personality difficulty|Detachment]]'' ({{ICD11|6D11.1}}),<ref name=":8" /> reflecting anxiousness, low self-esteem, and social withdrawal.<ref name=":8">{{Cite journal |last1=Simon |first1=Jonatan |last2=Lambrecht |first2=Bastian |last3=Bach |first3=Bo |date=2023-04-06 |title=Cross-walking personality disorder types to ICD-11 trait domains: An overview of current findings |journal=Frontiers in Psychiatry |language=English |volume=14 |article-number=1175425 |doi=10.3389/fpsyt.2023.1175425 |doi-access=free |issn=1664-0640 |pmc=10116048 |pmid=37091704}}</ref><ref name=":9" /> "The complete Avoidant PD pattern of Negative Affectivity and Detachment is overall consistent with the description of Avoidant PD patients as being both fearful and emotionally inhibited".<ref name=":9" /> Many studies also report a link to ''[[Anankastia in personality disorder or personality difficulty|Anankastia]]'' ({{ICD11|6D11.4}}), likely due to features such as emotional restraint and excessive caution aimed at avoiding negative outcomes.<ref name=":8" />

===Differential diagnosis=== There is debate as to whether avoidant personality disorder (AvPD) is distinct from [[social anxiety disorder]]. Both have similar diagnostic criteria and may share a similar causation, subjective experience, course, treatment and identical underlying personality features, such as shyness.<ref>{{cite journal |last1=Ralevski |first1=E. |last2=Sanislow |first2=C. A. |last3=Grilo |first3=C. M. |last4=Skodol |first4=A. E. |last5=Gunderson |first5=J. G. |author-link5=John G. Gunderson |last6=Tracie Shea |first6=M. |last7=Yen |first7=S. |last8=Bender |first8=D. S. |last9=Zanarini |first9=M. C. |last10=McGlashan |first10=T. H. |year=2005 |title=Avoidant personality disorder and social phobia: distinct enough to be separate disorders? |url=https://wesscholar.wesleyan.edu/cgi/viewcontent.cgi?article=1185&context=div3facpubs |journal=Acta Psychiatrica Scandinavica |volume=112 |issue=3 |pages=208–14 |doi=10.1111/j.1600-0447.2005.00580.x |pmid=16095476 |s2cid=16517625 |doi-access=free}}</ref><ref>{{cite journal |last1=Nedic |first1=Aleksandra |last2=Zivanovic |first2=Olga |last3=Lisulov |first3=Ratomir |year=2011 |title=Nosological status of social phobia: contrasting classical and recent literature |journal=Current Opinion in Psychiatry |volume=24 |issue=1 |pages=61–6 |doi=10.1097/YCO.0b013e32833fb5a6 |pmid=20966756 |s2cid=31505197}}</ref><ref>{{cite journal |last1=Reichborn-Kjennerud |first1=T. |last2=Czajkowski |first2=N. |last3=Torgersen |first3=S. |last4=Neale |first4=M. C. |last5=Orstavik |first5=R. E. |last6=Tambs |first6=K. |last7=Kendler |first7=K. S. |year=2007 |title=The Relationship Between Avoidant Personality Disorder and Social Phobia: A Population-Based Twin Study |journal=American Journal of Psychiatry |volume=164 |issue=11 |pages=1722–8 |doi=10.1176/appi.ajp.2007.06101764 |pmid=17974938 |s2cid=23171568}}</ref> In contrast to social anxiety disorder, a diagnosis of avoidant personality disorder (AvPD) also requires that the [[Personality disorder#DSM-5 general criteria|general criteria for a personality disorder]] be met.{{citation needed|date=October 2025}}

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.<ref>{{cite journal |last1=Reich |first1=James |year=2009 |title=Avoidant personality disorder and its relationship to social phobia |journal=Current Psychiatry Reports |volume=11 |issue=1 |pages=89–93 |doi=10.1007/s11920-009-0014-0 |pmid=19187715 |s2cid=40728363}}</ref><ref name="ReferenceA">{{cite journal |last1=Huppert |first1=Jonathan D. |last2=Strunk |first2=Daniel R. |last3=Ledley |first3=Deborah Roth |last4=Davidson |first4=Jonathan R. T. |last5=Foa |first5=Edna B. |year=2008 |title=Generalized social anxiety disorder and avoidant personality disorder: structural analysis and treatment outcome |journal=Depression and Anxiety |volume=25 |issue=5 |pages=441–8 |doi=10.1002/da.20349 |pmid=17618526 |s2cid=9179813 |doi-access=free}}</ref> In particular, those with AvPD experience not only more severe social phobia symptoms, but are also more depressed and more functionally impaired than patients with generalized social phobia alone.<ref name="ReferenceA" /> But they show no differences in social skills or performance on an impromptu speech.<ref>{{cite journal |vauthors=Herbert JD, Hope DA, Bellack AS |year=1992 |title=Validity of the distinction between generalized social phobia and avoidant personality disorder |url=https://digitalcommons.unl.edu/psychfacpub/917 |journal=J Abnorm Psychol |volume=101 |issue=2 |pages=332–9 |doi=10.1037/0021-843x.101.2.332 |pmid=1583228 |url-access=subscription}}</ref> Another difference is that social phobia is the ''fear of social circumstances'' whereas AvPD is better described as an ''aversion to intimacy'' in relationships.<ref name="Comer 2014 p.">{{cite book |last=Comer |first=Ronald |url=https://archive.org/details/FundamentalsOfAbnormalPsychologyComerRonaldJ.SRG].pdf |title=Fundamentals of abnormal psychology |publisher=Worth Publishers |year=2014 |isbn=978-1-4292-9563-5 |location=New York, NY |pages=424–427}}</ref>

Another personality disorder diagnosis could be more suitable for a presentation considered for a diagnosis of AvPD; however, these can also be diagnosed alongside AvPD, provided that the requirements for diagnosis are met for all of them (see {{Section link||Comorbidity}}). Specific features may indicate which diagnosis of several is the most suitable. [[Social isolation]] is also a prominent feature of [[Schizoid personality disorder|schizoid]] and [[Schizotypal personality disorder|schizotypal]] PDs; the significant difference between these and AvPD is that people with the former disorders may not experience discomfort stemming from it, whereas people with AvPD are likely to suffer from this isolation. Moreover, there are differences in what gives rise to the "feelings of inadequacy, hypersensitivity to criticism, and [...] need for reassurance" that AvPD shares with [[dependent personality disorder]]; while people with the former disorder worry excessively about being rejected and humiliated, those with the latter disorder experience a need of nurturance. Lastly, "reluctance to confide in others", which is also a feature of paranoid PD, "is attributable more to a fear of being embarrassed or being found inadequate than to a fear of others' malicious intent", as in the latter disorder.<ref name=":11" />

There is also an overlap between avoidant and schizoid personality traits and AvPD may have a relationship to the [[schizophrenia spectrum]].<ref>{{cite journal |author1=David L. Fogelson |author2=Keith Nuechterlein |year=2007 |title=Avoidant personality disorder is a separable schizophrenia-spectrum personality disorder even when controlling for the presence of paranoid and schizotypal personality disorders |journal=Schizophrenia Research |volume=91 |issue=1–3 |pages=192–199 |citeseerx=10.1.1.1019.5817 |doi=10.1016/j.schres.2006.12.023 |pmc=1904485 |pmid=17306508}}</ref> Avoidant personality disorder must also be differentiated from [[autism spectrum disorder]].<ref name="Lehnhardt2013">{{cite journal |last1=Lehnhardt |first1=Fritz-Georg |last2=Gawronski |first2=Astrid |last3=Pfeiffer |first3=Kathleen |last4=Kockler |first4=Hanna |last5=Schilbach |first5=Leonhard |last6=Vogeley |first6=Kai |date=November 2013 |title=The Investigation and Differential Diagnosis of Asperger Syndrome in Adults |journal=Deutsches Ärzteblatt International |volume=110 |issue=45 |pages=755–763 |doi=10.3238/arztebl.2013.0755 |pmc=3849991 |pmid=24290364}}</ref>

=== Subtypes ===

==== Millon's subtypes ==== Psychologist [[Theodore Millon]] notes that because most patients present a mixed picture of symptoms, their personality disorder tends to be a blend of a major personality disorder type with one or more secondary personality disorder types. He identified four adult subtypes of avoidant personality disorder.<ref name="Millon 11">[[Theodore Millon]] (2004): ''Chapter 6 – The Avoidant Personality'' (p.187). ''[http://dlia.ir/Scientific/e_book/Medicine/Internal_Medicine/RC_435_571_Psychiatry_/017437.pdf Personality Disorders in Modern Life.] {{Webarchive|url=https://web.archive.org/web/20170207112700/http://dlia.ir/Scientific/e_book/Medicine/Internal_Medicine/RC_435_571_Psychiatry_/017437.pdf|date=2017-02-07}}'' Wiley, 2nd Edition. {{ISBN|0-471-23734-5}}.</ref><ref name="millon.net">{{cite web |last=Millon |first=Theodore |date=2015 |title=Personality Subtypes Summary |url=http://www.millon.net/taxonomy/summary.htm |url-status=live |archive-url=https://web.archive.org/web/20170621092251/http://www.millon.net/taxonomy/summary.htm |archive-date=2017-06-21 |access-date=2013-01-08 |publisher=Institute for Advanced Studies in Personology and Psychopathology (millon.net)}}</ref> {| class="wikitable" |- ! Subtype !Features ! Traits |- | '''Phobic avoidant''' |Including [[Dependent personality disorder|dependent]] features | General apprehensiveness displaced with avoidable tangible precipitant; qualms and disquietude symbolized by a repugnant and specific dreadful object or circumstances. |- | '''Conflicted avoidant''' |Including [[Passive-aggressive personality disorder|negativistic]] features | Internal discord and dissension; fears dependence; unsettled; unreconciled within self; hesitating, confused, tormented, [[paroxysm]]ic, embittered; unresolvable angst. |- | '''Hypersensitive avoidant''' |Including [[Paranoid personality disorder|paranoid]] features | Intensely wary and suspicious; alternately panicky, terrified, edgy, and timorous, then thin-skinned, high-strung, [[wikt:petulant|petulant]], and prickly. |- | '''Self-deserting avoidant''' |Including [[Depressive personality disorder|depressive]] features | Blocks or fragments [[self-awareness]]; discards painful images and memories; casts away untenable thoughts and impulses; possibly suicidal.<ref name="millon.net" /> |}

==== Others ==== In 1993, [[Lynn E. Alden]] and [[Martha J. Capreol]] proposed two other subtypes of avoidant personality disorder:<ref>Peter D. McLean, Sheila R. Woody: ''[https://books.google.com/books?id=_cr_5BpEyGkC&pg=PA129 Anxiety Disorders in Adults: An Evidence-Based Approach to Psychological Treatment]''. p. 129, {{ISBN|978-0-19-802759-1}}.</ref> {| class="wikitable" |- ! Subtype ! Characteristics |- | '''Cold-avoidant''' | Characterised by an inability to experience and express positive emotion towards others. |- | '''Exploitable-avoidant''' | Characterised by an inability to express anger towards others or to resist coercion from others. May be at risk for abuse by others. |}

==Treatment== {{See also|List of investigational social anxiety disorder drugs}}

Treatment of avoidant personality disorder has been researched only to a minor extent,<ref name=":12" /> with a significant portion of the research being derived from studies of social anxiety disorder.<ref name=":12" /><ref name=":13" /> For AvPD, treatment can employ various techniques, such as [[social skills training]], [[psychotherapy]], [[cognitive therapy]], and exposure treatment to gradually increase social contacts, [[group therapy]] for practicing social skills.<ref name=":12" /><ref name=":13" /> While the use of pharmacotherapy for treatment of AvPD is not known to have been researched, it can be used for treating comorbid conditions and has proven to be useful in treating social anxiety disorder.<ref name=":12" />

A key issue in treatment is gaining and keeping the patient's trust since people with an 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 an avoidant personality disorder to begin challenging their exaggerated negative beliefs about themselves.<ref>{{cite web|author=Eckleberry, Sharon C.|title=Dual Diagnosis and the Avoidant Personality Disorder|date=March 25, 2000|work=The Dual Diagnosis Pages: From Our Desk|url=http://www.toad.net/~arcturus/dd/avoid.htm|access-date=February 6, 2007|archive-url=https://web.archive.org/web/20061216233724/http://www.toad.net/~arcturus/dd/avoid.htm|archive-date=December 16, 2006}}</ref> Significant improvement in the symptoms of personality disorders is possible, with the help of treatment and individual effort.<ref>{{cite web|title=Personality Disorder – Treatment|url=http://www.mind.org.uk/information-support/types-of-mental-health-problems/personality-disorders/treatment-and-support/|publisher=Mind|access-date=5 February 2016|archive-url=https://web.archive.org/web/20160205143748/http://www.mind.org.uk/information-support/types-of-mental-health-problems/personality-disorders/treatment-and-support/|archive-date=2016-02-05|url-status=live}}</ref>

== Prognosis == Having a personality disorder is usually chronic, and has long-lasting mental conditions.{{Clarification|date=June 2025|reason=What does having long-lasting mental conditions supposed to mean?}}{{CN|date=June 2025}} An avoidant personality disorder may not improve with time without treatment. Given that it is a poorly studied personality disorder and in light of prevalence rates, societal costs, and the current state of research, AvPD qualifies as a neglected disorder.<ref name=":13">{{cite journal | doi = 10.1007/s11920-016-0665-6 | volume=18 | title=Avoidant Personality Disorder: a Current Review | year=2016 | journal=Current Psychiatry Reports | author1=Weinbrecht, Anna |author2=Schulze, Lars |author3=Boettcher, Johanna |author4=Renneberg, Babette | issue=3 | page=29 | pmid=26830887 | s2cid=34358884 }}.</ref>

==Epidemiology== Reported to be at around 1.5%–2.5%, the [[prevalence]] of AvPD has also been estimated to be both lower and significantly higher than that.<ref name=":12">{{Cite journal |last1=Lampe |first1=Lisa |last2=Malhi |first2=Gin S. |date=2018-03-08 |title=Avoidant personality disorder: current insights |journal=Psychology Research and Behavior Management |language=English |volume=11 |pages=55–66 |doi=10.2147/PRBM.S121073 |pmid=29563846 |pmc=5848673 |doi-access=free }}</ref> In one study, it was seen in 14.7% of psychiatric outpatients,<ref>{{cite journal |author1=Zimmerman, M. |author2=Rothschild, L. |author3=Chelminski, I. |year=2005 |title=The prevalence of DSM-IV personality disorders in psychiatric outpatients |journal=The American Journal of Psychiatry |volume=162 |issue=10 |pages=1911–1918 |doi=10.1176/appi.ajp.162.10.1911 |pmid=16199838}}</ref> and its prevalence in clinical settings has been estimated between 5.1 and 55.4%.<ref>{{Cite book |last=Sperry |first=Len |title=Handbook of diagnosis and treatment of DSM-5 personality disorders: assessment, case conceptualization, and treatment |date=2016 |publisher=Routledge, Taylor & Francis Group |isbn=978-0-415-84190-0 |edition=Third |location=New York, NY}}</ref>{{Reference page|page=77}} It appears to occur with equal frequency in males and females.<ref name=":11" /> Some studies indicate a higher prevalence among women.<ref name=":12" />

=== Comorbidity === AvPD is reported to be especially prevalent in people with [[anxiety disorder]]s, although estimates of [[comorbidity]] 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 anxiety disorder. In addition to this, AvPD is more prevalent in people who have comorbid social anxiety disorder and generalised anxiety disorder than in those who have only one of the aforementioned conditions.<ref name="sciencedirect">{{cite journal |last1=Sanderson |first1=William C. |last2=Wetzler |first2=Scott |last3=Beck |first3=Aaron T. |last4=Betz |first4=Frank |date=February 1994 |title=Prevalence of personality disorders among patients with anxiety disorders |journal=Psychiatry Research |volume=51 |issue=2 |pages=167–174 |doi=10.1016/0165-1781(94)90036-1 |pmid=8022951 |s2cid=13101675 |doi-access=free}}</ref> [[Substance use disorder]]s are also common in individuals with AvPD<ref name=":12" />—particularly in regard to [[alcohol (drug)|alcohol]], [[benzodiazepine]]s, and [[opioid]]s<ref name=":3">{{Cite journal |last=Verheul |first=R |date=2001-08-01 |title=Co-morbidity of personality disorders in individuals with substance use disorders |journal=European Psychiatry |volume=16 |issue=5 |pages=274–282 |doi=10.1016/S0924-9338(01)00578-8 |pmid=11514129 |s2cid=29066695}}</ref>—and may significantly affect a patient's prognosis.<ref name=":1">{{Cite web |title=Personality disorders and substance use |url=http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/Publishing.nsf/content/FE16C454A782A8AFCA2575BE002044D0/$File/m718.pdf |url-status=live |archive-url=https://web.archive.org/web/20180327051653/http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/publishing.nsf/Content/FE16C454A782A8AFCA2575BE002044D0/$File/m718.pdf |archive-date=March 27, 2018 |publisher=[[National Drug Strategy]]}}</ref><ref name=":2">{{Cite web |title=Personality + substance use |url=https://ndarc.med.unsw.edu.au/sites/default/files/ndarc/resources/NDARC_PERSONALITY_FINAL.pdf |url-status=live |archive-url=https://web.archive.org/web/20171204061207/https://ndarc.med.unsw.edu.au/sites/default/files/ndarc/resources/NDARC_PERSONALITY_FINAL.pdf |archive-date=December 4, 2017 |publisher=[[National Drug and Alcohol Research Centre]]}}</ref>

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]].<ref>Van Velzen, C. J. M. (2002). ''Social Phobia and Personality Disorders: Comorbidity and Treatment Issues''. Groningen: University Library Groningen. ([https://nootropicsfrontline.com/wp-content/uploads/2021/07/wiki_Social-Phobia.pdf online version] {{Webarchive|url=https://web.archive.org/web/20211030082837/https://nootropicsfrontline.com/wp-content/uploads/2021/07/wiki_Social-Phobia.pdf|date=October 30, 2021}})</ref> [[Post-traumatic stress disorder]] and [[dependent personality disorder]] are also commonly comorbid with avoidant personality disorder.<ref name=":0">{{Cite journal |last1=Gratz |first1=Kim L. |last2=Tull |first2=Matthew T. |date=August 30, 2012 |title=Exploring the relationship between posttraumatic stress disorder and deliberate self-harm: the moderating roles of borderline and avoidant personality disorders |journal=Psychiatry Research |volume=199 |issue=1 |pages=19–23 |doi=10.1016/j.psychres.2012.03.025 |issn=0165-1781 |pmc=3407331 |pmid=22521897}}</ref><ref name=":11" /> People suffering from AvPD are prone to [[Self-hatred|self-loathing]] and, in certain cases, [[self-harm]].{{Medical citation needed|date=November 2025}}

Earlier theorists proposed a personality disorder with a combination of features from [[borderline personality disorder]] (BPD) and avoidant personality disorder, called "avoidant-borderline mixed personality" (AvPD/BPD).<ref>{{citation |last=Kantor |first=M. |title=Distancing: A Guide to Avoidance and Avoidant Personality Disorder |date=2003 |orig-date=1993 |edition=Revised |location=Westport, Connecticut |publisher=Praeger Publishers}}</ref>

==History== 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. [[Switzerland|Swiss]] psychiatrist [[Eugen Bleuler]] described patients who exhibited signs of avoidant personality disorder in his 1911 work ''Dementia Praecox: Or the Group of Schizophrenias''.<ref name=millon1995>{{cite book|last1=Millon|first1=Theodore|last2=Martinez|first2=Alexandra|editor-last=Livesley|editor-first=W. John|title=The DSM-IV Personality Disorders|chapter=Avoidant Personality Disorder|publisher=[[Guilford Press]]|year=1995|pages=[https://archive.org/details/isbn_9780898622577/page/218 218]|chapter-url=https://books.google.com/books?id=9AqPs9ootqoC&pg=PA218|isbn=978-0-89862-257-7|url-access=registration|url=https://archive.org/details/isbn_9780898622577/page/218}}</ref> Avoidant and [[schizoid personality disorder|schizoid]] patterns were frequently confused or referred to synonymously until [[Ernst Kretschmer|Kretschmer]] (1921),<ref>{{cite book|last=Kretschmer|first=Ernst|author-link=Ernst Kretschmer|title=Körperbau und Charakter|publisher=J. Springer|year=1921}}</ref> in providing the first relatively complete description, developed a distinction.{{citation needed|date=October 2025}}

==See also== {{Portal|Psychology}} * [[Attachment theory]] * [[Avoidance coping]] * [[Counterphobic attitude]] * [[Experiential avoidance]] * [[Inferiority complex]] * [[Sensory processing sensitivity]]

'''Social:''' * [[Hermit]] * ''[[Hikikomori]]'' * [[Loner]] * [[Recluse]] * [[Solitude]] * ''[[Taijin kyofusho]]''

==References== {{Reflist}}

==External links== {{Commons}} * [https://psychiatryonline.org/doi/pdf/10.1176/appi.focus.11.2.189 Alternative DSM-5 Model for Personality Disorders] (with AMPD definition of AvPD) {{Medical resources | ICD10 = {{ICD10|F|60|6|f|60}} | ICD9 = {{ICD9|301.82}} | MedlinePlus = 000940 | eMedicineSubj = ped | eMedicineTopic = 189 | MeshID = D010554 | ICD11 = {{ICD11|6D10}} }}

[[Category:Cluster C personality disorders]] [[Category:Humiliation]]