What is the best therapy for avoidant personality disorder?

Men and women with avoidant personality disorder (AVPD) experience a great deal of stress and anxiety in a variety of social situations. Their condition is not necessarily disabling, but the physical and psychological feelings of anxiety they suffer are so intense and unpleasant that they avoid interpersonal and social interactions whenever possible.

Underlying avoidant personality disorder are serious self-esteem problems. Those who have this condition are terrified of being judged as weak, unintelligent, inept, or inferior by other people, especially those they don’t know well. Whenever they are in the presence of people outside immediate family or close friends, they feel constantly scrutinized and highly vulnerable to criticism.

Complicating their pervasive social anxiety, people with AVPD have badly underdeveloped social skills, which can interfere with any relationships they do have. Their poor social development combined with a lack of self-confidence can make it difficult for them to find or hold down jobs, bringing extra stress and chaos into their lives.

While there is obvious overlap between social anxiety disorder and avoidant personality disorder, the latter condition is more deeply rooted and is more difficult to treat. Overcoming the worst effects of AVPD takes time and significant effort, but it can be done if treatment is comprehensive and if the person with the disorder is truly committed to change.

AVPD is classified as a Cluster C personality disorder, along with obsessive-compulsive and dependent personality disorders. Cluster C conditions are associated with high anxiety and emotional reactivity and are known to be generally disruptive to daily functioning.

While AVPD is not diagnosed before adulthood, signs are frequently observed in older children and adolescents.

Recent research suggests that between 1.5 and two percent of the adult population in the United States meet the criteria for avoidant personality disorder. But these figures may be low: it is possible that some people with AVPD have been misdiagnosed with social anxiety disorder, a condition that produces similar (but not identical) symptoms.

For people with avoidant personality disorder, social interactions of all types can be problematic. That creates tension and discomfort in situations that others take for granted, and it can alter behavior and life choices in profound and complex ways.

AVPD can be identified by a long list of emotional, behavioral, and psychological symptoms, which relate to anxiety or the need to avoid situations that might provoke anxious responses.

Some of these symptoms include:

• Extreme self-consciousness in social encounters
• Inability to initiate or continue conversations
• High sensitivity to criticism
• Anxiety to the point of panic (rapid heartbeat, dry mouth, sweaty hands, tightness of the chest, dizziness, etc.) in social situations, or when public speaking is required
• Avoidance of unfamiliar environments and/or people (even when avoidance creates significant life problems)
• Paranoia about what other people are saying or thinking
• Fear of blushing, stammering, or any other behaviors that would reveal anxiety and provoke laughter or rejection
• Defensiveness when asked personal questions
• Extreme dislike of conflict
• An unwillingness to ask for assistance or admit to true feelings
• Inability to express true opinions, for fear of being judged
• Harsh self-evaluations, based on awkward social performance or lack of life accomplishments
• Avoidance of unfamiliar environments and/or people

People with personality disorders generally see their behavior as rational if not always desirable, and they may be surprisingly resistant to change if the subject is broached. Nevertheless, a person with AVPD will suffer a variety of life problems and frustrations related to their personality disorder, and awareness of that reality may be enough to convince them to seek help (eventually).

Diagnosing Avoidant Personality Disorder

Under the most up-to-date diagnostic standards, a person can be diagnosed with avoidant personality disorder if they meet all of the following criteria:

Impairments in personality functioning

Impairments in self-functioning must be demonstrated in one of two areas:

• Identity. The person may have poor self-esteem or a profound lack of confidence, supporting chronic feelings of helplessness and inferiority.
• Self-direction. The person is restricted in their personal and professional pursuits because they fear embarrassment, rejection, or failure.

Impairments in interpersonal and social functioning must be observed in one of two areas:

• Empathy. Others are perceived as hostile and judgmental rather than sympathetic, which causes people with AVPD to avoid many social contacts.
• Intimacy. People with AVPD are obsessively worried about being scorned and rejected, which scares them away from intimate relationships and leaves them unable to be open and honest with others.

Pathological personality characteristics of detachment and negative affectivity

Pathological detachment manifests as:

• Chronic withdrawal from social situations
• Fear and avoidance of romantic relationships
• A loss of capacity to experience pleasure

Pathological negative affectivity manifests as:

• Chronic social anxiety in a broad range of social environments, which limits life success and causes many complications

For AVPD to be officially diagnosed, the above traits must be:

1. Consistent and stable over time
2. Experienced in multiple contexts and environments
3. Unexplainable by developmental processes, cultural standards, other mental health disorders, or medical conditions

For avoidant personality disorder, some of the most prominent risk factors include:

• Brain abnormalities. People with avoidant personality disorder experience intense bursts of anxiety, which are connected to neurological deficiencies in areas of the brain involved in stress response and emotional control.
• Family history. Genetic factors account for about one-third of the risk of avoidant personality disorder.
• Childhood abuse and neglect. Being abused during childhood is a risk factor for virtually every type of mental or behavioral health disorder, including AVPD. Studies indicate that parental neglect is often implicated in the development of AVPD as well.
• Temperament. Men and women with AVPD score high in measurements of harm avoidance, which is linked to neuroticism and shy or anxious personality traits. These personality characteristics will be evident in childhood and are likely related to a combination of heredity and early-life experiences.

Personality disorders are believed to emerge from interacting risk factors. Genetics and environmental exposures are both involved, and personality disorders may represent a psychological coping mechanism for those who feel overwhelmed by challenging circumstances.

A meta-analysis of research projects has revealed that people with anxiety disorders have co-occurring personality disorders between one-third and one-half the time. Cluster C personality disorders are experienced more often than Cluster A or Cluster B disorders, and avoidant personality disorder is the most common Cluster C disorder diagnosed in those with other anxiety-related conditions.

There is a clear relationship between social anxiety disorder and avoidant personality disorder. In some instances the two conditions may actually be diagnosed together, betraying the presence of a long list of anxiety symptoms that cannot be easily reduced to AVPD alone. Those who have both conditions tend to experience extreme and disabling symptoms of anxiety, and without treatment their lives will be filled with difficulty.

Meanwhile, major depression is a condition frequently found in people who have social anxiety disorder, and in one study it was diagnosed in nearly 30 percent of those who had AVPD. The risk factors for social anxiety and depression are similar, as are the neurological changes associated with their symptoms, and this connection seems to hold for depression and avoidant personality disorder as well.

While personality disorders are pervasive in nature, they still overlap with each other quite frequently. In the case of AVPD, people who have if often have borderline personality disorder as well, with studies suggesting that more than 40 percent of men and women with BPD will also meet the criteria for avoidant personality disorder.

It is common for people who experience chronic anxiety to self-medicate with substances, and that behavior may lead to a dual diagnosis for a mental health condition and addiction, which will require specialized treatment to overcome.

Avoidant personality disorder is amenable to treatment, and those who have it can learn to adjust to their emotional tendencies and develop strategies to reduce their disabling anxiety. Inpatient and outpatient treatment programs for AVDP will be comprehensive and customized to meet the unique needs of each patient, who often have co-occurring disorders that must be addressed during treatment as well.

Therapy forms the core of recovery plans for avoidant personality disorder, with individual, group, and family therapy sessions included to make sure the person receiving treatment has all the support they need to surpass their previous limits. Cognitive behavioral therapy (CBT), which helps those who receive it eliminate unproductive patterns of thinking and reacting, can be beneficial to men and women with anxiety problems, including those who have AVPD.

Because of their social anxiety, people with AVPD may find therapy stressful in the early stages. But during their time in residential recovery, the members of their treatment team will strive to make them feel comfortable, safe, and accepted for who they are.

In addition to the benefits they gain from therapy, people with AVPD can profit from various supplemental forms of treatment, including holistic mind-body practices like meditation, biofeedback, acupuncture, arts and music therapy, and yoga. These practices promote calmer states of mind that are highly useful for people with anxiety problems. Social skills and coping skills classes are also likely to be offered, since those whose lives have been disrupted by AVPD need practically-oriented instruction to boost their confidence and improve their social performance quickly.

Medications are not generally prescribed for personality disorders. However, when comorbid depression and/or anxiety disorders are present, antidepressants may be provided to help patients manage their most severe symptoms.

Avoidant personality disorder can be disabling and is always life-altering. But with the assistance of trained professionals and the compassionate support of friends, family, and peers in treatment, people with AVPD can rebuild their self-esteem, enhance their self-confidence, and re-emerge in the world feeling hopeful and empowered.