Prof. Joseph Levine

Conversation 63: Avoidant personality disorder in the perspective of the psychobiological model related to the social self

By Prof. Levine & Dr. Salganik

Hello to our readers,

The American diagnostic system DSM-5-TR divides personality disorders into cluster A, cluster B and cluster C. Each cluster encompasses a distinct group of personality disorders with common characteristics regarding symptoms, behaviors and basic psychological patterns.

Cluster A refers to personality disorders with odd or eccentric characteristics. These include paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder. Individuals within this cluster often exhibit social withdrawal, strange or paranoid beliefs, and difficulty forming close relationships.

Cluster B includes personality disorders with dramatic, emotional, or unstable behaviors. This cluster includes antisocial personality disorder, borderline personality disorder, histrionic personality disorder, and narcissistic personality disorder. Individuals within this cluster often exhibit impulsive actions, emotional instability, and challenges maintaining stable relationships.

Cluster C includes personality disorders with anxious and apprehensive characteristics. And these fears include avoidant personality disorder, dependent personality disorder and obsessive-compulsive personality disorder. People within this cluster tend to experience significant anxiety, fear of abandonment, or an excessive need for control or perfectionism.

Avoidant personality disorder (avoidant personality disorder) included in cluster C is characterized by a persistent pattern of social anxiety, heightened sensitivity to rejection, and pervasive feelings of inadequacy, along with an ingrained longing for meaningful connections with others.

AI-assisted illustration of an Avoidant Personality Disorder

A comprehensive and interesting review about this personality disorder appears in:

Fariba KA, Torrico TJ, Sapra A. Avoidant Personality Disorder. 2024 Feb 12. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 32644751.

There are several excerpts from it:

Historically, Swiss psychiatrist Eugen Blauler first described an avoidant personality type in his 1911 work Dementia Praecox: Or the Group of Schizophrenias. The German psychiatrist Ernst Kretschmer clarified the distinction between schizoid personality types and avoidant personality types in 1921.

In 1980, the Diagnostic and Statistical Manual of Mental Disorders (DSM), third edition, officially included avoidant personality disorder. Historically, there has been some controversy about similarities and differences between avoidant personality disorder and social anxiety disorder.

AI-assisted illustration of an Avoidant Personality Disorder

In general, research on the etiology of avoidant personality disorder is relatively limited, and qualitative studies that specifically investigate its causes are rare. Several factors are believed to contribute to the development of avoidant personality disorder, including genetic predisposition, childhood experiences, and environmental influences. However, it is important to note that the relative importance of these factors is still under investigation and debate.

From the point of view of object relations theory, we note that avoidant behaviors can be understood as arising from attachment problems in infancy, which evoke a strong fear of intimacy

During a conversation with them, patients with avoidant personality disorder lack self-confidence and often speak in a self-effacing manner. They may also hesitate to express themselves without asking permission from a family member, driven by their fear of potential rejection by the person in front of them or the clinician.

People with avoidant personality disorder may misinterpret others' comments about them as derogatory or derisive, leading to the need for frequent redirection to the normal interpretation of comments about them. Clinicians working with people with avoidant personality disorder need to be aware of these communication patterns and create a supportive environment that fosters trust and encourages open expression. It is essential to create a non-judgmental atmosphere where people with avoidant personality disorder feel safe to share their thoughts and feelings without fear of rejection or criticism.

The mental status examination, which is conducted during psychiatric evaluations, is essential for evaluating people with avoidant personality disorder. However, it is important to note that the specific components and findings of the test can vary according to each case of avoidant personality disorder. Patient assessment should include:

Appearance: Pay attention to the patient's general grooming and fashion choices. People with avoidant personality disorder tend to dress neutrally to avoid the risk of criticism or comments about their appearance. Clothes, accessories, hairstyles, and very prominent or eccentric tattoos are colors against the diagnosis of avoidant personality disorder.

Behavior: reserved and nervous behaviors, lowered gaze, difficulty making eye contact, or feeling uncomfortable when making eye contact with people with avoidant personality disorder. In addition, cooperation may vary depending on how the patient feels the clinician "loves" him.

Speech: People with avoidant personality disorder may exhibit decreased speech due to shyness.

Environmental impact: The impact may manifest as anxiety or other stress, especially in the uncomfortable environment of a clinical assessment.

Thought content: Thought content in people with avoidant personality disorder may center around a fear of being unloved; However, it is certainly not at the level of delusional or obsessive thoughts. Suicidal thoughts, especially regarding fear of abandonment, may be more suggestive of borderline personality disorder than avoidant personality disorder.

Thinking process: In people with avoidant personality disorder, the thinking process is expected to be linear and normal but limited in range and logic. Their fear of being judged tends to influence their thinking, leading to an increased focus on concrete and specific aspects of potential criticism.

Cognition: General cognition and orientation are not expected to be impaired in people with avoidant personality disorder.

Judgment: People with avoidant personality disorder's judgment about interpersonal situations is abnormal, as their fear of rejection is usually largely unfounded, but prevents them from making rational decisions about their interpersonal functioning.

Illustration with the help of AI: avoidant personality disorder wants a relationship but is afraid of it

We will now expand on the question of what is the difference between avoidant personality disorder and social phobia from a clinical, psychological and biological point of view.

Avoidant personality disorder and social phobia (also known as social anxiety disorder) share a number of overlapping symptoms, particularly around fear of social rejection and avoidance of social situations. However, there are differences in terms of their clinical, psychological and biological characteristics.

Clinical differences

Avoidant Personality Disorder: Avoidant personality disorder is a common pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. It is a personality disorder, meaning it reflects a consistent and persistent pattern that usually manifests itself in adolescence or early adulthood and affects many aspects of a person's life. People with avoidant personality disorder often struggle with forming close relationships because they fear criticism and deep rejection. Avoidance in avoidant personality disorder tends to be more general and widespread.

Social phobia (social anxiety disorder): This is classified as an anxiety disorder, where people experience intense fear or anxiety in specific social situations (such as speaking in public or meeting new people). Although it can be chronic, the anxiety is more often situational and does not encompass the entire social environment. Those with social anxiety tend to be less inhibited in close or familiar relationships and especially avoid situations where they expect to be evaluated.

Psychological differences

Avoidant Personality Disorder: Psychologically, avoidant personality disorder involves a persistent and fundamental belief in one's inferiority or worthlessness, leading to self-imposed isolation. People with avoidant personality disorder usually have a deeply ingrained schema that they are not interesting enough to be worthy or lovable, making it challenging for them to enter into relationships or trust others. They often have feelings of shame and are overly preoccupied with rejection and criticism, which shapes their personality.

Social phobia: The anxiety in social phobia usually centers around specific fears of embarrassment, negative evaluation, or making fun of oneself in certain social settings. While self-esteem may be low, the negative self-beliefs are less ingrained as part of the person's identity compared to avoidant personality disorder. Social phobia can respond well to exposure therapy and cognitive restructuring, which focuses on changing perceptions of specific social situations.

Biological differences

Avoidant Personality Disorder: Research on the biology of avoidant personality disorder is limited, but because it is a personality disorder, it may be related to differences in brain areas related to social cognition, emotional regulation, and self-concept (such as the amygdala and prefrontal cortex). Genetic predisposition, combined with early life experiences, especially chronic exposure to rejection or criticism, likely contribute to the development of avoidant personality disorder.

Social Phobia: Social phobia has been more widely studied biologically. It is often associated with hyperactivity in the amygdala, the brain region involved in processing fear and threat. There may also be neurotransmitter changes such as in the activity of serotonin, dopamine, and GABA, which affect anxiety. Social phobia tends to have a clearer biological basis in terms of a stress response, and treatment can include SSRIs (selective serotonin reuptake inhibitors) to help manage symptoms.

Avoidant personality disorder is a more common personality disorder with issues rooted in self-worth and a broader avoidance of interpersonal relationships, while social phobia is an anxiety disorder that focuses more narrowly on the fear of social situations.

In conclusion, psychologically, avoidant personality disorder involves ingrained self-perceptions of inferiority, whereas the anxieties of social phobia are more situational. Biologically, both may involve similar neural pathways, although social phobia has clearer links to neurotransmitter imbalances and increased amygdala activity.

Avoidant personality disorder (avoidant personality disorder) is usually treated with a combination of therapy, psychotherapy and, in some cases, medication. Avoidant personality disorder treatment focuses on helping people manage anxiety, build self-esteem, and develop healthier interpersonal skills.

Here are some common approaches:

Cognitive behavioral therapy (CBT)

Purpose: Helps people identify and challenge negative thinking patterns, especially those involving self-esteem and perceptions of others.

Approach: The techniques include cognitive restructuring, which aims to reframe negative thoughts about yourself and others, and heavy exposure therapy to gradually deal with fearful social situations in a controlled and supportive manner.

Schema therapy

Purpose: focuses on identifying and changing long-standing, deeply rooted patterns, or "schemas", that contribute to avoidance and low self-worth.

Approach: Schema therapy explores the origins of these negative schemas, often rooted in childhood, and uses therapeutic techniques to challenge and change them over time.

Psychodynamic therapy

Purpose: It aims to uncover unconscious conflicts or past experiences that may contribute to avoidant behaviors and low self-esteem.

Approach: This therapy delves into basic emotions, early relationships, and internal conflicts that are difficult to understand and treat the root causes of avoidant behaviors.

Dialectical Behavior Therapy (DBT)

Objective: Although originally developed for borderline personality disorder, DBT is also effective for avoidant personality disorder, especially when there are strong emotion regulation problems.

Approach: DBT emphasizes skills for emotion management, distress tolerance, and interpersonal effectiveness, helping people navigate social interactions more effectively.

Group therapy

Purpose: To provide a safe and structured environment for people with avoidant personality disorder to practice social skills and receive feedback.

Approach: Group therapy encourages participants to connect with others with similar struggles, allowing them to build social security in a supportive framework.

Administering medication

Purpose: Medications can be used to treat symptoms of anxiety or depression that often accompany avoidant personality disorder.

Options: Selective serotonin reuptake inhibitors (SSRIs), such as sertraline or fluoxetine, can help relieve anxiety and depression. However, medications are usually complementary to treatment rather than primary treatment.

Social skills training

Purpose: Helps people develop specific social skills to improve their confidence in social settings.

Approach: This training includes practicing skills such as initiating conversations, making eye contact and managing anxiety in social interactions.

Support and tolerance

Treating avoidant personality disorder requires a compassionate and gradual approach, as people with this disorder often fear criticism and rejection. A strong therapeutic alliance, patience and tolerance, and a non-judgmental approach are key factors in achieving progress.

A combination of these treatments, tailored to the individual's specific needs, can often yield the best results.

We will now move on and recall that in our model of the self includes the components of the human psyche. [See previous conversations, see figure below] The model first assumes the existence of the "primary self", which is actually the basic biological nucleus consisting of a number of innate structures and subject to increasing development during life, this self includes the instinctive emotional and cognitive parts of the person. The primary self uses the reservoirs and mechanisms of emotion, memory and cognitive abilities and it contains primary nuclei for the future development of other mental structures.

The primary self also includes the six Individual Sensitivity Channels (ISC) which reflect our individual reactivity in response to stressors (both external and internal). So far we have identified six sensitivity channels:

1. Sensitivity regarding a person's status and location (status channel)

2. Sensitivity to changes in norms (norm channel)

3. Sensitivity regarding emotional attachment to others (attachment channel)

4. Sensitivity to threat (threat channel)

5. Sensitivity for routine changes (routine channel)

6. Sensitivity to a decrease in energy level and the ability to act derived from it (energy channel).

Illustration of the model we are developing for SELF

From the primary self, a number of superstructures continue to develop [from innate nuclei that form a premordial basis for development during the interaction of the baby and later the person during his life with the people and events in his environment]:

1] The Experience Coordinating Agency

2] Three structures that together make up the secondary self or the social self, these include:

A] The group of the collection of internalized characters that we will metaphorically call the Board of Internalized Characters,

B] Enemies Group

C] The group of the self-representations.

AI-assisted illustration: the board of internalized figures

After this brief introduction about the model, we will derive several points arising from it in the context of avoidant personaliry disorder.

First, we suggest that three of the six sensitivity channels are relevant to this disorder:

A) The attachment channel [these individuals really want contact but are anxious about it]

B] the status channel [these individuals feel sensitive, inadequate and even inferior compared to others]

c) The threat channel [a threat evident in various social situations]

Second, we assume that among the board of internalized characters there is:

A leader figure who is humiliating, demeaning, criticizes or scolds, which contributes to the development and maintenance of the disorder, or alternatively, a very protective leader figure who prevents exposure to social and other life situations, and in fact conveys to the sufferer of the disorder that he/she cannot manage on his/her own.

These figures influence and project attitudes and feelings that become characteristic of the person’s self-representation.

Now we will ask: and what about the Experience Coordinating Agency?

Here it seems evident that the emotional salience network might be very alert to social situations and may be activating ruminations [internal repetitive thinking] of incompatibility, etc. through the brain's default network.

As mentioned in previous conversations, the treatment focused on the reference groups – Reference Group Focused Therapy (RGFT) is a method of treatment derived from the model for the self proposed above and deals mainly with the internalized figures and the sensitivity channels.

In the case of avoidant personality disorder, it is recommended to proceed with the following steps using this method:

A] Decrease in the hierchichal position of the internalized leader figures (leader selves) that adversely influence a person’s self-esteem

B] Utilizing the character of the therapist (that will be internalized as a treatment progressed) and/or a virtual character from literature or history and/or the already existing patient's internalized characters that support a patient’s self-esteem, in order to gradually rise them in the hierarchy of the directory of internalized characters until they becomes dominant and encourage positive changes in a patient.

C] Taking strategies to mitigate the expressions of the relevant channels of sensitivity while integrating exposure techniques both in imagination and in reality to pervent on one hand an avoidance response in social situations and on the other hand to encourage exposure to these situations and developing proper social skills.

Of course, it’s possible and even recommended to combine the techniques from the RGFT method treatment with other therapeutic approaches such as cognitive behavioral therapy and more, especially with the group therapy which serves as a kind of supporting laboratory for social interactions.

That's it for now,

Dr. Igor Salganik and Prof. Joseph Levine