Avoidant Personality Disorder (APD)

Avoidant Personality Disorder (APD)

Avoidant Personality Disorder (APD)

People with avoidant PD (APD) feel inadequate, are socially inhibited, and are overly sensitive to criticism. These characteristics are present throughout adult life, and affect most aspects of daily life. (Like narcissistic traits, avoidant traits are common in children and don’t necessarily imply eventual PD.)

Their sensitivity to criticism and disapproval makes these people self-effacing and eager to please others, but it can also lead to marked social isolation. They may misinterpret innocent comments as critical; often they refuse to begin a relationship unless they are sure they will be accepted. They will hang back in social situations for fear of saying something foolish, and may avoid occupations that involve social demands. Other than their parents, siblings, or children, they tend to have few close friends. Comfortable with routine, they may go to great lengths to avoid departing from their set ways. In an interview they can appear tense and anxious; they may misinterpret even benign statements as criticism.

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Although APD has appeared in the DSMs since 1980, relevant research is still sparse. In frequency, it occupies middle ground (about 2% of the general population) as PDs go, roughly equal for men and women. Many such patients marry and work, although they may become depressed or anxious if they lose their support systems. Sometimes this disorder is associated with having a disfiguring illness or condition. APD is not often seen clinically; these patients tend to come to evaluation only when another illness supervenes. There is considerable overlap with social anxiety disorder.

Essential Features of Avoidant Personality Disorder

These patients are socially inhibited, are overly sensitive to criticism, and feel inadequate. Feeling themselves inferior, unappealing, or clumsy, they are reluctant to form new relationships. Such people so fear ridicule or shame that they will only become involved with others if they can know in advance they will be accepted. Otherwise, their worry about being rejected or criticized (or embarrassed) on the job or in social situations will lead them to avoid new pursuits.

The Fine Print

The D’s: • Duration (begins in teens or early 20s and endures) • Diffuse contexts • Differential diagnosis (physical and substance use disorders, social anxiety disorder, paranoid and schizoid PDs)

Jack Weiblich

Jack Weiblich was feeling worse when he ought to be feeling better. At least, that’s what his new acquaintances in Alcoholics Anonymous had told him. One had reminded him that 30 days’ sobriety was “time enough to detox every last cell” in his body. Another thought he was having a “dry drunk.”

“Whatever a ‘dry drunk’ is,” Jack observed later. “All I know is that after 5 weeks without alcohol, I’m feeling every bit as bad as I did 15 years ago, before I’d ever had a drop. I’ve enjoyed hangovers more than this!”

At age 32, Jack had a lot of hangovers to choose from. He’d had his first drink when he was only a senior in high school. He had been a strange, lonely sort of kid who’d had a great deal of difficulty meeting other people. While he was still in high school, he had begun to lose his hair; now, with the exception of his eyebrows and eyelashes, he was totally bald. He was also afflicted with a slight, persistent nodding of his head. “Titubation,” the neurologist had said; “don’t worry about it.” The sight of his balding, nodding head in the mirror every morning looked grotesque, even to Jack. As a teenager he found it almost impossible to form relationships; he was positive that no one could like someone as peculiar as he was.

Then one evening Jack found alcohol. “Right from the first drink, I knew I’d discovered something important. With two beers on board, I forgot all about my head. I even asked a girl out. She turned me down, but it didn’t seem to matter that much. I had found a life.” But the following morning, he found that he still had his old personality. He experimented for months before he learned when and how much he could drink and maintain a glow sufficiently rosy to help him feel well, but not too rosy to function. During a 3-week period in his senior year at law school when he sobered up completely, he discovered that without alcohol, he still had the same old feelings of isolation and rejection.

“When I’m not drinking, I don’t feel sad or anxious,” Jack observed. “But I’m lonely and uncomfortable with myself, and I feel that other people will feel the same about me. I guess that’s why I just don’t make friends.”

After law school, Jack went to work for a small firm that specialized in corporate law. They called him “The Mole,” because he spent nearly all of every work day in the law library doing research. “I just didn’t feel comfortable meeting the clients—I never get along well with new people.”

The only exception to this lifestyle was Jack’s membership in the stamp club. From his grandfather, he had inherited a large collection of commemorative plate blocks. When he took these to the Philatelic Society, he thought they’d welcome him with open arms, and they did. He continued to build upon his grandfather’s collection and attended meetings once a month. “I guess I feel OK there because I don’t have to worry whether they’ll like me. I’ve got a great stamp collection for them to admire.”

Evaluation of Jack Weiblich

Jack’s symptoms were pervasive (profoundly affecting his work and social life) and had been present long enough (since he was a teenager) to qualify for a PD. They included the following typical APD features: He avoided interpersonal contact (for example, with clients at the law firm—criterion A1); he felt that he was unappealing (A6); although he joined the stamp club, he was pretty sure that his collection would be accepted (A2); he worried a lot about being rejected (A4). Only four criteria are needed; cognitive, occupational, and interpersonal areas were involved for Jack Weiblich (see the Essential Features for a general PD earlier in this chapter).

Depression and anxiety are both common in patients with APD. Therefore, it is important to search for evidence of mood disorders and anxiety disorders (especially social anxiety disorder) in patients who avoid contact with others. Jack stated explicitly that he felt neither sad nor anxious, but he admitted that he had severely misused alcohol. The substance-related disorders also commonly bring a patient with APD to the attention of mental health care providers.

In both APD and schizoid PD, patients spend most of their time alone. The difference, of course, is that patients with APD are unhappy with their condition, whereas people with schizoid PD prefer it that way. A somewhat more difficult differential diagnosis may be that between APD and dependent PD. (Dependent patients avoid positions of responsibility, as Jack did.) Note that Jack’s avoidant lifestyle may have been bound up in his twin physical peculiarities, his baldness and nodding head.

Although Jack had an alcohol use disorder, his clinician felt that it was causing him little current difficulty and that the PD was the fundamental problem needing treatment (other clinicians might argue with this interpretation). That’s why the PD was listed as his principal diagnosis. Of course, he didn’t qualify for any course modifiers for alcohol use disorder, because he’d only been on the wagon for 5 weeks (p. 409); I thought his alcoholism was pretty mild, actually (and note that the PD doesn’t enter into the coding of the substance use disorder; see Table 15.2in Chapter 15). I’d put his GAF score at 61.