Today we move on to the Cluster C personality disorders, which are known as the “anxious” or “fearful” disorders. The first of these is Avoidant Personality Disorder (AvPD).

In 1911, Swiss psychiatrist Bleuler wrote about people who shied away from most social contact and activities. Bleuler is better-known for coining the words schizophrenia and schizoid, and he interpreted people’s avoidance through that lens; he assumed severe social avoidance was part of an unnoticed type of schizophrenia. However, this opinion was not widely accepted, and within ten years others described severe social avoidance as a separate condition.

AvPD is leagues beyond being shy and introverted. Instead, it is a deep-rooted and severe fear of rejection and criticism which impacts almost every aspect of a person’s life. While someone with AvPD will want to connect with and develop friendships with others, their fear of being criticised and disapproved of can be so painful that they are unable to take part in social activities. Their self-loathing and feelings of inferiority may be so strong that they assume others would not want to interact with them. As a result, they often interpret neutral statements as containing hidden rejections or reminders of their perceived social inability, which reinforces their perception of being socially inadequate.

The DSM-5 describes AvPD as a widespread pattern of being inhibited around people, feeling inadequate, and being very sensitive to any negative judgements. To be diagnosed with AvPD, someone must meet 4 of these criteria:

• They avoid occupational activities that involve significant interpersonal contact because they fear criticism, disapproval, or rejection.
• They are unwilling to get involved with people unless they can be certain of being liked.
• They show restraint within close relationships because of the fear of being shamed or ridiculed
• They are preoccupied with being criticized or rejected in social situations.
• They are inhibited in new social situations because they feel inadequate
• They seem themselves as socially inept, personally unappealing, or inferior to others
• They are unusually reluctant to take personal risks or to engage in new activities in case they embarass themseleves.

No specific conditions need to be ruled out before a diagnosis of AvPD, but a psychiatrist must ensure substance abuse or a physical health condition did not cause the person’s symptoms. Approximately 2.3% of people in the USA have been diagnosed with AVPD, while data is patchy for other countries. While more people may fit the criteria, they may not be able to ask for help due to their fear of being rejected or judged. People may seek help for anxiety, or for feelings of depression which result from their experiences with AvPD, without anyone identifying the underlying AvPD traits.

One character who demonstrates many AvPD traits is Shinji Ikari, from the anime Neon Genesis Evangelion. The typical anime hero is loud, brash, confident to a fault, and very focused on others, but Shinji is the opposite. He is described as “shrinking from human contact” due to his incredibly low self-worth. Even although he wants to connect with others he expects to be judged negatively and rejected by them. He also continually doubts, and tries to run away from, his combat responsibilities; he reluctantly agrees to fight only when shown how other people would be harmed if he refused.

Social skills/awareness training and group therapy can help someone with AvPD practice connecting with others in a safe environment. It can also be used to help them evaluate their social behvaviours, as their anxiety can cause maladaptive social behaviours that lead to the rejection they fear. Medication can be used to reduce people’s accompanying anxiety, but there is no medication specifically for AvPD.

Psychological Criticisms of AVPD

AVPD is strongly linked to anxiety disorders; one study found that 22% of people diagnosed with Generalised Anxiety Disorder also met the criteria for AvPD. Social Anxiety Disorder (otherwise known as Social Phobia) also includes extreme shyness, social withdrawal, and feeling socially inept. The main difference is their prevalence; while ~7% of Americans in any given year could be diagnosed with Social Phobia, it is a short-term condition for most of them.

Because AvPD and Social Phobia share symptoms and are linked to some of the same genetic vulnerabilities, some researchers see AvPD as a severe form of Social Phobia rather than a separate condition. Some researchers believed that AvPD could be the result of untreated social phobia affecting a person’s life so strongly that they eventually meet the general personality disorder criteria. However, this is hard to study in more detail, partly because obtaining information and data from people with SP or AvPD can be difficult. The DSM and ICD criteria for both conditions have changed slightly in each revision, so the amount of overlap between both diagnoses has varied over time.

Critics of psychiatry often claim that Social Phobia (and sometimes even AvPD) are examples of psychiatry making a medical issue out of shyness and introversion, or that people are labelled as impaired simply because they are different. While this argument holds for some mental health conditions due to how their diagnostic criteria have loosened in recent versions of the DSM, this argument doesn’t apply to AvPD. Instead, it ignores the negative consequences and life disruptions caused by the symptoms of AvPD.