How best can a cognitive-behavioral therapist treat a person with avoidant personality disorder?

Avoidant personality disorder (AVPD) is a mental health condition that can impair daily functioning. Marked by feelings of inferiority, people with AVPD have an intense need to connect to others, but often avoid social situations out of fear of being rejected, criticized or disliked.

Although they can occur together, AVPD is not the same thing as social anxiety disorder. AVPD is thought to be a more complex mental disorder, while social anxiety tends to manifest as a more straightforward condition that involves increased, obvious anxiety in social situations. Additionally, individuals living with AVPD may have more debilitating symptoms than individuals living with social anxiety.

Rates of AVPD in the general population vary from 0.8% to 5.2%, and AVPD is thought to be one of the most prevalent of the personality disorders, which include borderline personality disorder, paranoid personality disorder and dependent personality disorder, among others.

AVPD often presents alongside other mental health conditions, such as depression, obsessive compulsive disorder, anxiety disorder, social phobia or an additional personality disorder.

“Most people avoid uncomfortable or awkward situations. This is not AVPD,” says Amanda K. Lopez, a licensed marriage and family therapist in Vista, California. “AVPD causes significant distress, as do all personality disorders.”

There is no scientific consensus on the exact cause of AVPD. However, possible indicators include the following:

• Genetics: Personality disorders may have a genetic component, meaning those with family members living with personality disorders may be more likely to develop a similar condition themselves.
• Early childhood temperament: Some research suggests behavioral markers in early childhood, such as rigidity, hypersensitivity, increased inhibition and risk avoidance, may be precursors to AVPD.
• Early childhood distress: Neglect, abuse and poor attachment to caregivers in early childhood may also play a role in developing AVPD. Studies suggest prolonged distress in infancy may lead to dysfunctional coping mechanisms, such as distrust, hypervigilance and a preoccupation with avoiding stressful situations.

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“People with AVPD experience an intense fear that others are criticizing, judging and rejecting them. They also avoid social situations at work and in their personal life,” says Lopez. “In intimate relationships, someone with AVPD may refrain from and/or avoid emotional or physical connection with their partner or friends for fear of being shamed.”

An individual must meet four of the following criteria to be diagnosed with AVPD, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the standard guide clinicians use to diagnose patients with mental health conditions:

• Avoids interpersonal activities for fear of being criticized, disliked or rejected
• Avoids others unless they can ensure approval or acceptance beforehand
• Inhibited by shame or embarrassment in romantic relationships
• Experiences severe distress over potential criticism or rejection by peers
• Shows restraint in new social settings because they feel inadequate
• Experiences feelings of inferiority, social ineptitude and of being unlikable
• Risk averse due to fear of being embarrassed

“People with AVPD have an intense drive to connect to others,” says Lopez, noting that despite this drive, “their fear of connecting, unless they are sure of acceptance, often leaves them feeling isolated and withdrawn. Isolation from others can lead to other illnesses such as depression.”

Because self-esteem issues are at the core of AVPD, individuals with the condition can live in a self-fulfilling cycle where their worries of being judged or rejected results in unconscious behavior that can push others away.

Whether a person’s feeling of isolation are real or imagained, AVPD can often be a precursor to chronic depression, and may increase the risk of suicidal ideation as well. In new parents, preexisting AVPD is linked to a higher risk of postpartum depression.

In addition, research suggests individuals with an AVPD diagnosis may have lower levels of education, a weaker connection to social networks and a lack of strong friendships. Those with AVPD may also turn to substance abuse as a way of coping with their symptoms.

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The road to a diagnosis may begin with your primary care physician. There, your provider may choose to rule out an underlying cause of your symptoms by performing a physical exam and ordering lab tests. From there, you may be referred to a mental health professional who will use the criteria from the DSM-5 to make an assessment, says Lopez.

As mentioned above, before a diagnosis can be made, you and a mental health professional must decide you are living with at least four of the symptoms listed in the DSM-5.

This process can often be complicated by the fact that the main symptoms of AVPD, like anxiety, low self-esteem and social ineptitude, are common in other mental health conditions and personality disorders.

Treatment options for AVPD include medication and psychotherapy, says Lopez. Because personality disorders are life-long and pervasive, she notes that treatment is meant to ease symptoms, rather than eliminate them.

Here’s a closer look at possible treatments for AVPD.

Psychotherapy

There are a few types of therapy that may help individuals living with AVPD. Psychodynamic therapy, which works to link a person’s past—which can involve neglect or trauma—to how their current behaviors are protecting them from that pain when interacting with others, is one type of talk therapy that can be very effective.

Another type of talk therapy called cognitive behavioral therapy (CBT) is also often used for individuals with AVPD, says Lopez. “[CBT] has shown to be effective to lessen distress by teaching the client to challenge their negative thoughts while slowly exposing them to their stressors,” she adds. In older studies, CBT has been shown to possibly be more effective in treating AVPD than other therapeutic approaches, but more research needs to be done before any conclusions can be made.

Medications

There are no pharmaceutical options to treat AVPD specifically, though medications may be prescribed to treat some of the symptoms, or those of a comorbid diagnosis. Research shows the medications used to treat social anxiety disorder, such as serotonin-specific reuptake inhibitors (SSRIs), are effective at relieving symptoms of AVPD as well.

While avoidant personality disorder can greatly affect someone’s life, with proper treatment and support, individuals living with this condition can learn how to strengthen their social ties and work towards finding symptom relief.