Avoidant personality disorder: symptoms, causes and treatment

Key points

• Avoidant personality disorder, or AvPD, is a long-standing pattern of social inhibition, feeling inadequate, and strong sensitivity to criticism or rejection [10].
• It runs across most situations and most of adult life, not only particular settings [10].
• Whether it is separate from social anxiety disorder is disputed, and a large literature treats the two as one problem at different severities [1][9].
• About 0.8% of adults met the criteria in a national survey in Great Britain, and it is the most common personality disorder among people treated for social anxiety [1][7].
• There is no NICE guideline and no NHS pathway, the trial base is small, and the strongest evidence is for adapted cognitive behavioural therapy [5][8].

What avoidant personality disorder is

Avoidant personality disorder is a long-standing pattern of social inhibition, feelings of being inadequate, and marked sensitivity to criticism and rejection [10]. It is described as extreme shyness linked to low self-esteem: a person finds it hard to make friends, feels uncomfortable socially, and may avoid work involving contact with people [10].

If you need help now. Samaritans: call 116 123, free, 24/7. Shout: text SHOUT to 85258. NHS 111, then choose the mental health option. Call 999 if anyone is in immediate danger.

A personality disorder is diagnosed when someone’s way of thinking, feeling and behaving differs from what their culture expects, causes distress, and lasts over time [10].

In a survey of households across England, Scotland and Wales, 0.8% of adults met the criteria, against 4.4% for any personality disorder [7]. Only obsessive-compulsive personality disorder was more common, at 1.9% [7]. England’s 2023/4 survey did not assess it [6].

Symptoms

The same wish for closeness and fear of exposure appear in thought and action [10].

Thinking and feeling:

• a belief of being inferior, unappealing or not good enough [10]
• an expectation of being criticised or turned down [10]
• loneliness, because the wish for company remains [10]

Behaviour:

• avoiding work or study involving contact with others [10]
• holding back from friendships unless certain of being liked [10]
• keeping personal feelings private for fear of rejection [10]

The pattern runs across settings and over years [10]. It is commonly mistaken for shyness, introversion or low confidence, and for depression, complex PTSD, autism or ADHD [3].

Its closest neighbour is social anxiety disorder, and the boundary is disputed. The case for one condition: the criteria overlap heavily, most people with the personality diagnosis also meet criteria for social phobia, and some experts call it a severe variant of social anxiety disorder [1][9]. The case for two: those with the personality diagnosis report more severe childhood neglect and work far less [9]. NICE’s review notes that some researchers put the association down to how long the anxiety has run [1].

Types

Avoidant personality disorder has no recognised subtypes. Two systems describe it.

• The ICD-11 approach. UK practice changed in 2022 to describing severity and traits rather than named types [3]. Severity runs from personality difficulty to severe personality disorder [3]. The traits are negative affectivity, detachment, dissociality, disinhibition and anankastia, plus a borderline pattern [3]. An avoidant presentation usually appears as detachment with negative affectivity [3].
• The DSM-5-TR approach, used in most research. Avoidant personality disorder stays a named category with its own criteria [10].

Causes and risk factors

There is no single cause. The NHS describes personality disorders as resulting from a mix of inherited genes and early environment, such as a distressing childhood [2].

• Childhood neglect. In a Norwegian study of 91 patients, those with avoidant personality disorder reported more severe childhood neglect, particularly physical neglect, than those with social phobia alone, and the difference held after allowing for abuse and temperament [9]. The sample was small.
• Long-running social anxiety. Some researchers argue the pattern is largely what happens when social anxiety disorder runs for many years [1].

Two popular explanations are weaker than they sound: that this is a personality flaw, and that a personality disorder is fixed for life. NICE’s review reports that successful psychological treatment of social anxiety also reduces the rate of avoidant personality disorder [1].

How it is diagnosed

In the UK a personality disorder is usually identified by a psychiatrist or a qualified psychological professional, not a GP, normally after a GP referral to a community mental health team [4]. Some areas allow self-referral [4].

Assessment is a long interview about patterns across adult life, not a scan or blood test. Research and surveys use the Structured Clinical Interview for DSM Axis II disorders [7]. No reliable national figure exists for waiting times, and what is available varies by area [4].

The diagnosis is easy to miss. Up to 61% of adults seeking treatment for social anxiety also meet criteria for a personality disorder, most often this one [1]. Many people are treated for depression or social anxiety while the wider pattern goes unnamed.

A diagnosis names a recognised pattern and points towards treatment. It is not a statement about a person’s worth [2].

Treatment

There is no NICE guideline for avoidant personality disorder, and NHS Talking Therapies does not treat it. The service manual states these services “are not designed to treat other mental health problems such as psychosis, bipolar disorder, ‘personality disorders’ or eating disorders” [5].

What the evidence supports:

• Cognitive behavioural therapy adapted for the avoidant pattern. In the main randomised trial, 62 people received 20 weekly sessions of cognitive behavioural therapy, 20 of brief psychodynamic therapy, or a waiting list place [8]. Cognitive behavioural therapy did better than both: at follow-up 9% still met criteria, against 36% after brief psychodynamic therapy [8]. This is one trial, of moderate size, not run in the UK.
• Schema-focused therapy works on beliefs about the self formed early in life. No large trial has tested it in this condition alone.
• Treating a co-occurring social anxiety disorder. NICE’s review reports this also reduces the rate of avoidant personality disorder [1]. It is often the treatment people actually receive.
• Therapies used in NHS personality disorder services: dialectical behaviour therapy, mentalisation-based therapy, structured clinical management and cognitive analytic therapy [4]. These were developed mainly for the borderline pattern, and the evidence in avoidant presentations is thin.

The NHS notes talking therapy may run for months or years, and that medication is used for problems occurring alongside a personality disorder rather than for it [2]. Decisions about medication are made with a GP or prescriber.

Living with avoidant personality disorder

What you do between appointments matters.

• Keep a diary of situations, thoughts and actions, so the pattern becomes visible [4].
• Take social contact in small graded steps, choosing one you expect to manage.
• Watch alcohol and drug use, both common ways of getting through social contact [4].

At work or university you do not have to disclose a diagnosis. If you choose to, ask for specific adjustments: written instructions rather than group briefings, or notice before presenting.

NHS provision varies by area [4]. Support outside it includes local Mind branches, Mind’s Side by Side community, Rethink Mental Illness, and NHS service user networks run by people with the diagnosis [2][4].

When to speak to a professional

Speak to your GP if avoiding people is shaping your work, study, friendships or daily life, and has done so for years rather than during a bad patch [2].

Get in touch sooner if:

• you are turning down work, study or medical appointments to avoid people
• low mood or hopelessness has developed alongside the avoidance
• you are drinking or using drugs to manage social situations
• you have been treated for anxiety or depression but the wider pattern was never examined

If you are thinking about harming yourself, contact Samaritans on 116 123, free and 24/7, text SHOUT to 85258, or call NHS 111 and choose the mental health option. Call 999 if anyone is in immediate danger.

Common questions

Is avoidant personality disorder the same as social anxiety disorder?

This is genuinely unsettled, and both cases are set out above. One study gives a sense of the gap in functioning: 29% of the avoidant group were working half time or more, against 60% of those with social phobia alone [9].

Can avoidant personality disorder be treated?

There are treatments with evidence behind them, though the trial base is small. Cognitive behavioural therapy adapted for the pattern outperformed brief psychodynamic therapy and a waiting list in the main trial [8]. Treating a co-occurring social anxiety disorder also reduces the rate [1].

Why is it so rarely diagnosed in the UK?

It is not part of NHS Talking Therapies, which handles most anxiety and depression treatment in England [5]. England’s national survey does not measure it [6]. Most research has been done inside samples of people with social phobia [9].

Clinical review pending

References

1. National Collaborating Centre for Mental Health, commissioned by the National Institute for Health and Care Excellence. Social anxiety disorder: recognition, assessment and treatment. Full guideline, 2013. https://www.nice.org.uk/guidance/cg159/evidence/full-guideline-pdf-189895069
2. NHS. Personality disorder. nhs.uk. https://www.nhs.uk/mental-health/conditions/personality-disorder/
3. Mind. About personality disorders. mind.org.uk. https://www.mind.org.uk/information-support/types-of-mental-health-problems/personality-disorders/about-personality-disorders/
4. Mind. Self-care for personality disorder. mind.org.uk. https://www.mind.org.uk/information-support/types-of-mental-health-problems/personality-disorders/self-care/
5. NHS England. NHS Talking Therapies for anxiety and depression Manual, version 7.1. https://www.england.nhs.uk/wp-content/uploads/2018/06/nhs-talking-therapies-manual-v7.1-updated.pdf
6. NHS England Digital. Adult Psychiatric Morbidity Survey: Survey of Mental Health and Wellbeing, England, 2023/4. Chapter 8: Personality disorder. https://digital.nhs.uk/data-and-information/publications/statistical/adult-psychiatric-morbidity-survey/survey-of-mental-health-and-wellbeing-england-2023-24/personality-disorder
7. Coid J, Yang M, Tyrer P, Roberts A, Ullrich S. Prevalence and correlates of personality disorder in Great Britain. The British Journal of Psychiatry, 2006, volume 188, issue 5, pages 423 to 431. https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/prevalence-and-correlates-of-personality-disorder-in-great-britain/A9F8F2585369857C24C2C46672EECF6E
8. Emmelkamp PMG, Benner A, Kuipers A, Feiertag GA, Koster HC, van Apeldoorn FJ. Comparison of brief dynamic and cognitive-behavioural therapies in avoidant personality disorder. The British Journal of Psychiatry, 2006, volume 189, issue 1, pages 60 to 64. https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/comparison-of-brief-dynamic-and-cognitivebehavioural-therapies-in-avoidant-personality-disorder/0D34F813868B3000CC4542DD29EA25E5
9. Eikenaes I, Egeland J, Hummelen B, Wilberg T. Avoidant personality disorder versus social phobia: the significance of childhood neglect. PLOS ONE, 2015, volume 10, issue 3, e0122846. https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0122846
10. American Psychiatric Association. What are Personality Disorders? psychiatry.org. https://www.psychiatry.org/patients-families/personality-disorders/what-are-personality-disorders