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Aspect Avoidant Personality Disorder Generalized Social Anxiety Disorder
Key feature Hypersensitivity to negative evaluation by other people which results in social withdrawal and low self-esteem. A marked and persistent fear of most social or performance situations in which embarrassment may occur [8].
Diagnostic Criteria (DSM-IV) [6]
(possibly abridged)		 A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:
  1. avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection
  2. is unwilling to get involved with people unless certain of being liked
  3. shows restraint within intimate relationships because of the fear of being shamed or ridiculed
  4. is preoccupied with being criticized or rejected in social situations
  5. is inhibited in new interpersonal situations because of feelings of inadequacy
  6. views self as socially inept, personally unappealing, or inferior to others
  7. is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing
  1. A marked and persistent fear of most social or performance situations (1) in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing.
  2. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed Panic Attack.
  3. The person recognizes that the fear is excessive or unreasonable.
  4. The feared social or performance situations are avoided or else are endured with intense anxiety or distress.
  5. The avoidance, anxious anticipation, or distress in the feared social or performance situation(2) interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
  6. In individuals under age 18 years, the duration is at least 6 months.
  7. The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder.
  8. If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it.
Diagnostic Criteria (ICD-10)
(possibly abridged)		 Personality disorder characterized by at least 3 of the following:
  1. persistent and pervasive feelings of tension and apprehension;
  2. belief that one is socially inept, personally unappealing, or inferior to others;
  3. excessive preoccupation with being criticized or rejected in social situations;
  4. unwillingness to become involved with people unless certain of being liked;
  5. restrictions in lifestyle because of need to have physical security;
  6. avoidance of social or occupational activities that involve significant interpersonal contact because of fear of criticism, disapproval, or rejection.
Associated features may include hypersensitivity to rejection and criticism. 		All of the following criteria should be fulfilled for a definite diagnosis:
  1. the psychological, behavioural, or autonomic symptoms must be primarily manifestations of anxiety and not secondary to other symptoms such as delusions or obsessional thoughts;
  2. the anxiety must be restricted to or predominate in particular social situations; and
  3. avoidance of the phobic situations must be a prominent feature.
Comorbidity Dysthymic Disorder, major depression, anxiety disorders.

Individuals with AvPD may have comorbidity with some other personality disorder such as DPD (Dependant Personality Disorder), BPD (Borderline Personality Disorder), and more severe schizophrenic disorders [4]. 		80% of patients with any type of SAD meet diagnostic criteria for a comorbid condition [10].

The most common comorbid conditions include major depression, PTSD, panic disorder, substance abuse disorder and schizophrenia [9].
Prevalence 0.5%-1.0% For all types of SAD: Lifetime Prevalence (occurs at least once in a lifetime): 13.3% Annual Prevalence rate: 7.9% [5].

The Anxiety Disorders Association of America (ADAA) (2002) reported that SAD of all types affects 3.7% of the population [9].
Age of onset Onset is in adolescence or early adulthood.

Cannot be diagnosed until adulthood (age 18). 		For all types of SAD: Onset typically occurs between 11 and 19 years of age. Onset after age 25 is rare [7].

Mean age of onset is between ages 14 and 16 [9].
Sex distribution Found equally in both males and females [6]. Slightly more females than males have any type of SAD [7].
Etiology Weak evidence of major biogenic influences; full development of AvPD is likely due to significant environmental influences, including parental rejection or peer rejection [3]. Predisposing factors include biochemistry (physiological imbalance in neurotransmitters), genetics, childhood upbringing (overly cautious, overly critical or assertiveness-suppressing parents) and cumulative stress [1].
Personality traits Avoidant Personality Disorder Generalized Social Anxiety Disorder
Extroversion Significantly higher levels of low extroversion (introversion) than in SAD [2].
Self-Esteem View themselves as defective, unable to fit in with others, being unlikable, and being inadequate. Individuals with AvPD usually refer to themselves with contempt [4]. Low self-esteem may begin in early childhood and often fuels social anxiety and avoidance. High self-esteem does not contradict the existence of SAD. [1]
View of Others Individuals with AvPD view the world as unfriendly, cold, and potentially humiliating; they come to expect that attention from other people will be degrading or rejecting [4].
Sensitivity Slightly higher levels of interpersonal sensitivity and mistrust in AvPD than in SAD [2].
Reaction to criticism Individuals with AvPD tend to respond to low-level criticism with intense hurt [4].
Neuroticism Significantly higher levels of neuroticism in AvPD than in SAD, with or without other comorbid personality disorders [2].
Functioning Avoidant Personality Disorder Generalized Social Anxiety Disorder
Social Severe social inhibition and feeling of social inadequacy and inferiority [1].

Greater disability on all levels than in SAD [2].
Intimate Relationships Appear self-involved and uncaring, but long for affection and fantasize about idealized relationships [4].

Restraint in intimate relationships; few or no close friends [1], but intimacy is possible with people who are experienced as safe [4]. 		Roughly the same level of impairment in AvPD as in SAD, given the absence of other comorbid personality disorders [2].
Occupational More impaired in AvPD than in SAD; greater disability on all levels [2].
Physical Symptoms Blushing, heart palpitations, shortness of breath, sweating and trembling [9].

Slightly more somatic complaints in patients with SAD than with AvPD. [2]
Treatment Avoidant Personality Disorder Generalized Social Anxiety Disorder
Medications Unlike many other personality disorders, AvPD responds to antidepressants [1].

MAOIs (Nardil, Parnate), SSRIs, SNRIs, benzodiazepines (Klonopin, Xanax, for non-drug-addicts). 		SSRIs (Paxil, Celexa, Lexapro, Zoloft, Luvox) are considered drugs of first choice although MAOIs (Nardil) and benzodiazepines (Klonopin, Xanax) are often more effective.

Beta-blockers are not known to be effective for generalized SAD.
Therapy CBT, CBGT.

Behavioral therapy consisting of graduated exposure, social skills training, and systematic de-sensitization [4].

Cognitive therapy consisting of alteration of patterns of negative self-talk [4]. 		CBT, CBGT.

The presence of Avoidant Personality Disorder in SAD does not influence long-term outcome of behavioral therapy [2].



Resources:

[1]Signe A. Dayhoff (2000). Diagonally-Parked in a Parallel Universe – Working Through Social Anxiety. Pages 42, 45-59, 78-79
[2]Carol J. M. van Velzen, et al. Social phobia and personality disorders: comorbidity and treatment issues. 2002. (www.ub.rug.nl/eldoc/dis/ppsw/c.j.m.van.velzen/thesis.pdf)
[3]http://open-mind.org/SP/Articles/1c.htm
[4]Sharon C. Ekleberry, 2000. Dual Diagnosis and the Avoidant Personality Disorder. (http://www.toad.net/~arcturus/dd/avoid.htm)
[5]http://www.fpnotebook.com/PSY12.htm
[6]DSM-IV, 1994
[7]. J. Bruce et al. Social Anxiety Disorder: A Common, Underrecognized Mental Disorder. American Academy of Family Physicians (http://www.aafp.org/afp/991115ap/2311.html)
[8]Pollack MH. Comorbidity, neurobiology, and pharmacotherapy of social anxiety disorder. J Clin Psychiatry 2001
[9]Andrea Gwosdow. Focus on Social Anxiety Disorder. Psychiatric Times. 2003.
[10]den Boer JA. Social anxiety disorder/social phobia: epidemiology, diagnosis, neurobiology, and treatment. Compr Psychiatry 2000.


Remarks:

(1) Some of the references discuss discrete/specific social anxiety as well. In this comparison we refer strictly to generalized social anxiety disorder unless specified otherwise.
(2) The form AvPD is often used as an acronyms for Avoidant Personality Disorder, instead of APD, which also stands for Antisocial Personality Disorder, a different condition. AvPD is also called the "withdrawn pattern" or "anxious (avoidant) personality disorder".



MEMBERS' NOTES (first is most recent) ADD NOTE     SORT BY: NAME / DATE
Re: Avoidance... by sociallyConstructed
Mojo: I'd say that sounds about right. I dislike a lot of people and find myself having negative and cynical thoughts about people and on a wider scale about society. In the past it was to almost a point of misanthropy, but I've mitigated some of thatand now I find myself appologizing for others and wishing I was more like them instead of having negative thoughts. Though, I find that I dislike people more than they dislike me. Generally I seem to be well liked but as soon as someone says a comment to me that I consider negative or condescending I develop and aversion and will go out of my way to avoid them.   (Sun Jul 29 23:46 2007)

genetic / AvPD and SAD / by sociallyConstructed
Mark Priscilla: it's possible that environmental modelling / learning leads to family members expressing similar personalities and behaviors. I don't think you should write it off as being genetic when it's not definitive that this is the case -- then it seems even more changeless and impossible to feel better.

Erika: there can be significant overlap on the two -- AvPD is an older DSM characterization whereas social anxiety is relatively new. My suspicion is that AvPD may involve deeper negative cognitions whereas SAD involves more direct physiological fear responses. Apparently AvPD is more debilitating in that whereas someone with strong anxiety may still go through with the routine they hate but someone with AvPD just won't bother at all. ata shows that SAD + AvPD is harder to treat that SAD alone and that exposure (facing situations you fear to get habituated or "used to them" requires more graduated and smaller steps.   (Sun Jul 29 23:37 2007)

some rambling by sociallyConstructed
this feels insurmountable... since I can recall being conscious I can recall feeling this way... I suspect comorbid with SAD. I've been to a therapist twice but it doesn't seem like it's helped me yet. The conversation is somewhat relieving while we have it, but I find myself thinking more about my issues and having greater troubles sleeping. Since I graduated college I don't really see anyone other than my family and one or two friends occasionally. In college I would drop classes if I discovered they had necessary speaking and presentation components. I avoid people because I'm unemployed and hate the judgement which that brings. I even go out of my way to avoid any potential small talk with neighbors where this issue could arise. I fear seeking work because I know employers follow an ideology which won't make them understandable to any personal issues which they will merely regard as "laziness". the notion of having to sell myself and project some sort of assertive attitude is painful. I've sucessfully avoided mostly all events in life which require any sort of social formalities, such as weddings, funerals, high school dances, and the like. Even casual socialization that is not one on one I feel completely out of place and nervous with. Almost all of my socialization aside from those mentioned above come from the computer. I'm 25 and have never had an intimate relationship with a woman. I feel completely alienated from the standards and values of this societies with emphasis on aggressive competitive material attainment. I can really identify with the mention of another posters of fantasy as being a means of escape -- during my childhood and adolescence I obsessively collected toys and comic books and engaged in videogame playing which i could lose myself in, which probably contributed to a good lack of exposure and social skills development. Anyhow, having little money to seek effective treatment like CBT and parents who tend to dismiss my problems or to compare their experience to mine in order to minimize it is pretty damn frusterating. *sigh*    (Sun Jul 29 23:24 2007)

#48987 by avpd
I am 27 and have lived with avpd for many years although I have been misdiagnosed with other problems previously. I am midway through therapy now, and finally I see results!
Reading the above negative statements that some people have made about themselves and the world has been very interesting. I am just coming to terms now with the fact that my negative thoughts about myself might not be true.
Also I'm learning to manage my anxiety whilst climbing the 'exposure ladder', as well as many other CBT techniques and much more. Life is beginning to look worth living again.
I very highly recommend going to a Psychologist specializing in CBT and SFBT (Solution Focussed Brief Therapy). I have been to a few psychologists and the tight (but adaptable) SFTB structure seems to produce results quickly.
Good luck everyone.    (Fri Jun 8 12:16 2007)

RE: annonymous by Anistasya
thx for warning me about the meds.. Aren't their behavior
modification programs for these disorders that would be
preferable to the hell you just described? Thats what I think
I'll end up doing.. Hopefully some1 will be able to talk me
out of being scared. But idk what I'll do if that doesnt end up
working.   (Wed May 16 23:52 2007)

dpd/avp/ocd by annonymous
dpd mom&dad=Anxiety&DPD son =Hyperactive to Gr7=withdrawn to fit in=Anxiety/AVDP/OCD as  an outlet for anxious stress and not being able to fit in as yourself=selfhate & Low self Esteem & Depression=Alcohol to interact socially.Low self-esteem & DPD = settling for less in relationships & dealing with screwed up partners as a result. So afraid of rejection,real or imagined your defeated before you begin.Wasted Time goes by-Your 34 Unhappy confused & Nasty to yourself and those around you.You get help from MD.Doctor = Paxil =colors are brighter,mind is clear of thoughts for 1st time in your life.You can sleep.Youve got tons of energy & ideas.You dont take crap from anyone.Your not a doormat anymore.Three months later your more tired.Doctor sends you to Psychiatrist and you end up on Serzone = Superior to Paxil.Eventually you can endure anything & feel powerful,BUT you lose alot of your humanity with the Anti-Depressants and you dont feel quite yourself=Machine-like.Your there but you dont really know why your there.You go back to Psychiatrist & you try Wellbutrin = What an Upper!Your bouncing off the walls with energy & cant stop smiling.BUT you still dont feel human.You phase out the anti-depressants and phase in 1000mgFish-oil,1000mgOmega369,Multi-vit,calciumZincMag pill taken in morning only.After one month OCD is less than with anti-depressants & you feel human for first time in years.Time goes & youve still got the DPD & AVPD.You visit a Psychologist & Research the Internet to find out more info on causes of DPD & AVPD.43Years in Journey so far.NOTE Knowledge is Power,BUT when your mental vision is impaired its hard to tell one illnesses symtoms from anothers without professional guidance.NOTE mixing anti-depressants and other medications ie]even antibiotics or muscle relaxers gave me the urge to be nasty to or even hurt people as if I was in a daydream state.Anti-depressant can make you feel cold or inhuman BUT when youve felt afraid or anxious your whole life this is a Powerful feeling.You do not regret anything you do while your on anti-depressants,BUT you do after your off them.Anti-depressants are good for clearing your head,decreasing your sensitivity,giving you cold aggressive energy BUT in alot of ways you end up similar on them as you did before them and with less humanity.They take away your worry & anxiety BUT it also doesnt bother you if life passes you by or if people die or if you go into debt or if your not happy.They NUMB you into not caring about the things which either bothered you or worried you or were important to you in the past.Good things or Bad things anti-depressants cant tell them apart.   (Sun Feb 19 15:52 2006)

avoidance personality disorder by pam
i sometimes go days without opening my door, i really wish i could be diagnosed correctly.   (Thu Jan 12 23:16 2006)

See the right Shrink! by Finally Help!
I have be suffering since I was a around 11.  I never used to know what the hell was wrong with me.  I could fake it pretty well sometimes but the feelings and thoughts were persistent and miserable.  I have abused drugs and alcohol for 20 years.  It sucked but at least it made the unbearable fear go away.  I lost myself into fantasy.  Video games became a GREAT outlet. (Just one of many.)  If you feel you have AvPD try medication.  I have tried to think my way out for so long.  I also see many of the same traits in my family, although everyone's life experience is different and respond different ways.  The part that sucks is that people just think that you can change your attitude because in most other ways we can seem kind of normal.  I was terrified of what a doctor would think.  F-it. The pain got so bad.  My life was wasting away.  I was trapped inside my head.  See a GOOD psychiatrist, explain your experiences, and don't give up. There is medication (legal, non-addictive, and socially acceptable). God is a big plus too.   (Tue Dec 20 8:49 2005)

AvPD by Scared
I am a 39 year old recovering bulimic and alcoholic and am convinced that I have AvPD.  I will go to any lengths to avoid social situations (fake illness).  If I didn't have to I would probably never leave the house.  It is effecting my husband who doesn't understand it and my children who can't seem to understand why mom never wants to go anywhere.  I'm tired of being scared of everyone and everything...any feedback would be appreciated...Thanks   (Mon Dec 12 12:42 2005)

#14762 by Tired
I'm tired of having to deal with this.  Tired emotionally and physically.  I'm at a point where I hate people.  Being around them rattles me and small talk gets on my nerves.  The criticisms, the gossipping, the insensitivity, all of it makes me just want to withdraw and be on my own.  

I started seeing a psychologist earlier this year for SAD but I think I have AvPD too.  I expected more from the treatment.  I thought that by this time I would be a lot better.

#13308 by Joseph
I'm 21 years old from NJ. I was never diagnosed officially, but i'm very sure I have AvPD among some other minor disorders that makes my case unique. I doubt that it's SAD because for example; I used to work as a guard and i'd open all the gates, lock the doors, close the shades, and i'd blast the tv and ignore drivers that would knock asking for directions. I just didn't like when they brought small talk into it.. It annoyed me because I had to plan my reaction. I'm also very much preoccupied with roleplaying games online and unrealistic fantasies, so I tend to lose focus at times on realistic goals.. Like getting ahead! I applied to 15 jobs and not one called me back... I really loathe them. They just didn't like me when I went to those places to fill at apps, that's why i saw that some were grinning for no reason.. Made me want to hurt them. I hate when they do that. Anyway, I guess they just don't want me to succeed in life, they want me to fail. I would say some things that I hope happens to them, but I don't wanna seem like a bad guy ha. Just having a hard time..as usual. I hope one day I am problem-free.. That would be a first!   (Sun Jul 24 5:14 2005)

AvPD & PTSD by Sara
All these years never knew what was wrong - but now I do! PTSD symptoms & while doing internet research on Post Traumatic Stress Disorder am 95% sure I also suffer from AvPD for a very long time. Just read a site that says being rejected by your parents as a child, is the biggest factor in developing AvPD. Both parents rejected me, I blame that for sure & maybe genetic causes. The big question now, is what to do? It's very frightening. Is it related to schizophrenia? Does anyone know? Does it get worse as time goes on? Today is the first day of discovering about AvPD.   (Sun Jul 3 7:54 2005)

AvPD by Priscilla
After a move to a new state at 16, I began feeling inadequate with low self-esteem and socially inept.  Dealing with people became too painful, so I withdrew into my own fantasy world of daydreaming and reading.  These feelings have been with me throughout adulthood limiting my occupational choices.  Now at 55 some of the feelings are going away but I still prefer to be alone most of the time.  Even though I have a Masters Degree, I still feel inadequate in my job. However I am confortable with more people and able to interact with others as needed.  I have also been treated with antidepressants since 1996 for severe depression.  My mother and one of my sister's appear to be the same as I am. I also have a daughter with bipolar disorder and BPD.  I believe a lot of this is genetic.   (Wed Jun 29 20:20 2005)

avoidance... by mojo
I am extremely avoidant, however, I am not aware of any fear of humilation by others.  Maybe this is simply because I have followed the impulse to avoid whatever I dont want to deal with, and haven't really dealt with the reasons for that -- desperately fear failure however, and basically feel like I am totally incompetent for living, even though I've been fairly successful...this feeling persists, along with doubting that anyone could ever love me (excepting family and friends of course).  In my mind, I don't like people, rather than them not liking me, but I wonder if this is merely some kind of convoluted defense, on my end -- does anyone else cope with social anxiety in this fashion?  Which is to say, by avoiding people, and generally, not liking people very much or wanting to be around them while feeling desperately lonely, isolated and sad?  Feel very confused about this.   (Tue Jun 28 17:01 2005)

AvPD by Ericka
Is AvPd a branch of Social Anxiety?   I heard somewhere that AvPD is a severe form of Social Anxiety.  I have been dealing with AvPD since I was 15 or 16 (I am 23 now) and I am trying to get treated.   (Wed Jun 22 21:20 2005)

Genetic Factors by Mark
I have AvP. It's onset was triggered by peers after moving to a new state. I am curious how much research has been done into heredity. I suspect that both my parents have social anxiety (or AvP). I've always believed that I was born with personality weaknesses that made me vulnerable to AvP. I'm skeptical of the statement that the relationship between AvP and heredity is "weak".   (Sat Apr 9 14:05 2005)

Both Disorders by Jilly
I have been trying to find out what is wrong with me.  I know I am not like everyone else.  I don't fit in.  I do have SAD, but also fit into the AvPD category.  I also can see the DPD as well.  You knew this was so complex!  I wonder if I could ever get enough help to feel better about this stuff.   (Thu Mar 17 0:09 2005)

overcomeing, acceptance and recoverery by nicola
i posted my last message in january. i am still awaiting my apointment with a theropist, but am making good recovery by myself too. i have come to belive that many disorders come from intovert thinking. ie, if someone says something about brown hair, you think its about you, bcoz u have brown hair. the idea is to think to yourself 'maybe the thought didnt even cross her mind that i had brown hair too'. that was my first step.second is to realise the importance of somethings. if a person you dont like, says something horrible to you, you should you feel bad? you dont like them, there for what is their importance of their opinion?
i think now days we relie on what the majority of people think, and we fear to be differnt, which is where i think social anxiety disorder come from. a fear to be differnt, and because maybe you are, you would rather keep withdrwn, than let peopel realise your differntness. creating a routine habbit of avoidance. and leading on to further problems.
that is what ive come to find
nicola x   (Mon Feb 28 11:08 2005)

#9210 by nicola
i have avpd, but have soem physicla sympoms of sad, it sux, but printing out this page, and ticking which things i felt, helped my diagnoses, he was gna send me away, becasue i couldnt explain it right. luckily i brang it, he made his decition from this, so i advise anyone to do the same.
nicola

#8750 by scared
i have only my own painful reasons to believe that i must be Avoidant.  i try not to imagine what others think because it hurts to much.  i feel like crying everyday but somehow i end up falling asleep hoping for a better day, waking to the same.  what kind of occupation will work with my sensitive affect?  i have noticed that not only am i an annoyance but others manage to be annoyed at even themselves in my presence.  i dont want to make anyone feel like that away or around me.  i guess i will just sulk alone forever?

#7542 by Joma
I understand.. people don't really believe me either

#7120 by WAYNE
I am 38 now and i have been trying to live with avpd for about 25 years and i find it difficult to get help i feel like no one believes me   (Wed Sep 15 6:47 2004)

#4227 by John
I am not a psych health professional, and
this is my opinion derived from observation:

Social Anxiety Disorder would be much more
likely to arise from one's own consumption
rather than a physical/developmental problem
caused by a mother's drinking.  If the
parents are alcoholic, the child would be
likely to be more withdrawn, which can result
in SAD and/or AvPD developing later in life.

However, if a child with visible fetal
alcohol effects is taunted or ridiculed
by classmates in early school years, this
can cause SAD and/or AvPD.
   (Thu Feb 12 1:40 2004)

#1897 by dpepgirl
I was wondering how much of the social anxiety could come from fetal alcohol effects

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