Avoidant Personality Disorder Historical Developments

Although the term avoidant personality was first used by Millon, several clinical theorists throughout the twentieth century have referred to related personality constructs. Jung, in his 1936 paper on psychological typology, described the “introvert” as having a distinct dislike of society, appearing awkward and inhibited and having feelings of inferiority. He stated that the introvert “has an everlasting fear of making a fool of himself…he is overcritical, pessimistic and worried…never feels accepted.” This type of person can have warm relations with other people “only when safety is guaranteed…and consequently the number of friends and acquaintances is very restricted”.

Later, Horney described the “interpersonally avoidant” person as one who experiences “intolerable strain” in associating with other people and asserted that “solitude becomes primarily a means of avoiding it”. She referred to the general tendency of these persons to “suppress all feeling, even to deny its existence” and also to “never become so attached to anybody or anything so that he [or she] or it become indispensable…but to have nothing matter much”.

In her landmark book published in 1950, Neurosis and Human Growth, Horney also described the cognitive stance of the avoidant person:

On little or no provocation he feels that others look down on him, do not take him seriously, do not care for his company, and, in fact, dislike him. His self contempt…makes him…profoundly uncertain about the attitudes of others toward him. Being unable to accept himself as he is, he cannot possibly believe that others, knowing him with all his shortcomings, can accept him in a friendly or appreciative spirit.

Millon’s social learning theory of avoidant personality disorder is consistent with psychodynamic object relations theories. He described the “active detached” pattern as representing “fear and mistrust of others.” This results in patients’ efforts to maintain a “constant vigil lest their impulses and longing for affection result in a repetition of the pain and anguish they have experienced with others previously.” He further explained that “they actively withdraw in order to protect themselves. They have the desire to relate, but they have learned it is best to deny these feelings and to keep an interpersonal distance”.

These and other clinical theorists helped to inform the American Psychiatric Association committee that formulated the criteria for avoidant personality as first introduced in DSM-III in 1980. The DSM-III criteria for avoidant personality disorder stressed the pervasive and generalized timidity, inhibition, and avoidance typical of this disorder. DSM-III-R reflected some shift in the theoretical viewpoint of this disorder and attempted to demarcate it more clearly from its near neighbors, especially dependent personality disorder. Trait criteria such as “desire for acceptance” and “low self-esteem,” initially considered central to the formulation of this disorder, were deleted, and new criteria, such as “fear of being embarrassed by blushing” and “fear of saying something inappropriate,” were added because they emphasized the aspects of social avoidance most central to the core of the avoidant personality disorder construct. At the same time, however, the Axis I diagnosis of social phobia was expanded to introduce a “generalized type” of this disorder, resulting in the distinctions between these two constructs becoming considerably blurred. Several studies before the publication of DSM-III-R had suggested that avoidant personality disorder could be distinguished clinically from social phobia. Avoidant personality disorder was viewed as a disorder characterized by more serious impairment; higher levels of anxiety, depression, and general distress; and greater deficits in social skills, interpersonal sensitivity, and avoidant behaviors.

With the support of the few published empirical findings regarding avoidant personality disorder, as well as unpublished data relevant to its prevalence and descriptive validity, DSM-IV (American Psychiatric Association 1994) introduced changes intended to strengthen the distinctions between avoidant personality disorder and other Axis II disorders and to reduce the overlap with social phobia. The criterion of “low self-esteem” that had been deleted from the DSM-III criteria was altered to be consistent with existing data and descriptive literature and also consonant with the ICD-10 criteria. The new criterion 6 is “views self as socially inept, personally unappealing, or inferior to others”.

A second new criterion was developed by combining DSM-III-R criteria 6 and 7 to reduce the overlap with the criteria for social phobia. This new criterion 7 is phrased “is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing”. Items were sequenced so that the most prominent symptoms came first. The essential feature of avoidant personality disorder was defined as “a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation” (

Table 86-1).

Preliminary empirical evidence for the validity of the DSM-IV construct for avoidant personality disorder was offered by Numberg and colleagues. Their study of 110 outpatients with personality disorders found that six of the seven DSM-III-R criteria for avoidant personality disorder contributed significant unique data for the 26 outpatients meeting criteria for avoidant personality disorder. DSM-III-R criterion 2, which did not provide unique information, was eliminated from the DSM-IV criteria, and the essential features of the other six were subsumed into the new definition. A second study of 80 outpatients with avoidant personality disorder who presented for treatment to a specialist treatment facility for anxiety disorders also found support for the validity of DSM-III-R criteria for avoidant personality disorder as a distinct disorder. The elimination of criterion 2 also was partially supported by the data. The authors stated that criteria 1 and 7, although not dropped from the DSM-IV set, had been “substantially revised in a way which, on face value, should strengthen their relationship with [avoidant personality disorder]”. They also suggested that the alterations in former criteria made to create criteria 1, 3, and 5 may improve the distinction between social phobia and avoidant personality disorder.

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Revision date: June 22, 2011
Last revised: by David A. Scott, M.D.