Avoidant personality disorder: Definition, clinical and neurobiological profiles, differential diagnosis and therapeutic framework

Abstract

This work focuses on the analysis of the general, clinical, neurobiological and therapeutic profiles of the disorder under examination, suggesting a particular attention to the elements that could make a difference in relation to healing or better management of symptoms, often aggravated by frequent comorbidities

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Citation: Perrotta G (2021) Avoidant personality disorder: Definition, clinical and neurobiological profiles, differential diagnosis and therapeutic framework. J Neurol
Neurol Sci Disord 7(1): 001-005. DOI: https://dx.doi.org/10.17352/jnnsd.000041
https://dx.doi.org/10.17352/jnnsdDOI:
2641-2950
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CLINICAL GROUP
Contents of the manuscript
Defi nition and general profi les
The present personality disorder, disciplined by the DSM-V
[1], in cluster C, is characterized by a penetrating pattern
of behaviour of social inhibition, feelings of inadequacy,
extreme sensitivity to negative evaluations towards oneself
and the tendency to avoid social interactions. Most individuals
sometimes use avoidance to relieve anxiety or to prevent
diffi cult situations. Avoiding personality disorder, on the
other hand, is characterised by a pervasive pattern of social
inhibition, feelings of inadequacy and hypersensitivity to
negative assessments. People with this disorder are concerned
about being ridiculed by others, rejected or criticised. This leads
them to avoid social situations in which they have to interact
with others by limiting the normal development of social
skills over time. People with personality avoidance disorder
generally live in isolation, spectators of a world in which they
would like to take part but which is too scary for them. They
tend, in fact, to think that they are not good enough, that they
can be rejected or hurt, that others do not like them, that they
are unattractive and socially inadequate. These thoughts lead
to high states of anxiety in social situations, such as work,
friends, intimate relationships, which they tend to avoid
carefully for fear of being ridiculed, criticized and rejected. The
pre-eminent condition is “social distress and anxiety” and a
marked tendency to lead a routine life that shelters these people
from the potential risks of novelty. In order to live positive and
gratifying sensations, even if temporary, the avoiders cultivate
solitary interests and activities. Finally, social withdrawal
confi rms their personal sense of social inadequacy, in an
apparently endless spiral. People with avoidant personality
disorder often consider themselves socially incapable or
unattractive on a personal level and avoid social interactions
for fear of being ridiculed, humiliated or objects of dislike.
Despite the diffi culties and strong inhibitions, however, people
with this disorder would like to have social relationships;
unlike other personality disorders in which the person
avoids interaction but at the same time is not interested in it.
However, the avoidance disorder is diagnosed at the beginning
of adulthood even though the symptoms usually exist from
childhood; it is no coincidence that strong associations have
been found with emotional neglect, particularly rejection by
one or both parents, or perceived rejection by the peer group
[2-8].
Abstract
This work focuses on the analysis of the general, clinical, neurobiological and therapeutic profi les of the disorder under examination, suggesting a particular attention
to the elements that could make a difference in relation to healing or better management of symptoms, often aggravated by frequent comorbidities.
Review Article
Avoidant personality disorder:
Defi nition, clinical and
neurobiological profi les,
differential diagnosis and
therapeutic framework
Giulio Perrotta*
Psychologist sp.ing in Strategic Psychotherapy, Forensic Criminologist, Legal Advisor sp.ed SSPL,
Researcher, Essayist, Istituto per lo studio delle psicoterapie - ISP, Via San Martino della Battaglia n. 31,
00185, Rome, Italy
Received: 11 February, 2021
Accepted: 01 March, 2021
Published: 02 March, 2021
*Corresponding author: Dr. Giulio Perrotta, Psy-
chologist sp.ing in Strategic Psychotherapy, Forensic
Criminologist, Legal Advisor sp.ed SSPL, Researcher,
Essayist, Istituto per lo studio delle psicoterapie - ISP,
Via San Martino della Battaglia n. 31, 00185, Rome,
Italy, E-mail:
https://www.peertechzpublications.com

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https://www.peertechzpublications.com/journals/journal-of-neurology-neurological-science-and-disorders
Citation: Perrotta G (2021) Avoidant personality disorder: Definition, clinical and neurobiological profiles, differential diagnosis and therapeutic framework. J Neurol
Neurol Sci Disord 7(1): 001-005. DOI: https://dx.doi.org/10.17352/jnnsd.000041
The cause of the avoidable personality disorder is not
clearly defi ned, and can be infl uenced by a combination of
social, genetic and biological factors. Specifi cally, various
anxiety disorders in childhood and adolescence have been
associated with a temperament characterised by behavioural
inhibition, including characteristics of shyness, fear and
introversion in new situations. Many people diagnosed with
the avoidant disorder have had previous painful chronic
experiences of criticism and rejection by parents or peers,
due to their psychological characteristics (shyness, conduct
disorders, oppositional-provocative disorder, attention
defi cit/hyperactivity disorder) or physical defects that are not
accepted. In particular, the need to bond with parents “prone to
rejection” makes the person affected by the disorder “hungry”
for relationships, but his great desire gradually develops into a
defensive “shell” of self-protection against repeated parental
criticism. Many others, on the contrary, claim to have had
problems with ultra-protective parents that prevented him
from developing his own personality [9-16].
The neural correlates
The interest in literature for this disorder has re-emerged
only in recent years, with the advent of instrumental
examinations in case of studying related neurobiological
processes. In this perspective, the interest in the scientifi c
literature has privileged the examination of multiple aspects
and domains, including cognitive and attentional bias, coping
strategies, metacognitive abilities, comorbidity with other
disorders, general functioning, quality of life, and more.
To these is added the current attempt in neuroscience to
identify the neurobiological correlates and neural mechanisms
involved in the emotional regulation of the disorder under
analysis. The data emerging from a recent study, conducted
through the use of functional neuroimaging, shows that
a central role in the hypertrophy of the anxious response
to social stimuli in subjects affected by this disorder can be
traced back to a high reactivity of the amygdala both in the
phase preceding the stimulus and in that of actual exposure.
To this end, the authors have prepared an experimental task
through which to measure the different reactions in front of
the negative social stimulus. The subjects of the experiment
are given an instruction on the behaviour to adopt towards
the visually presented stimulus. The sequence is divided into
5 steps: listening to a recorded audio instruction (‘Look at
the image’ or ‘Assume critical distance from the image’), 1-3
seconds interval, appearance of the stimulus, evaluation of
the emotional intensity experienced and fi nally indication of
the degree of detachment from the stimulus. Each subject was
also given a questionnaire to evaluate anxiety of state and tract
anxiety. The results of the study suggest that patients present a
higher bilateral activity of the amygdala than the control group
of healthy subjects during the early evaluation of the negative
social stimulus. This observation is repeated in the negative
stimulus exposure phase, although amygdala hyperactivity
appears more intense in the right region. In the fi rst case
the level of amygdala activation correlates signifi cantly with
tract anxiety, while in the second case it correlates with state
anxiety. There are, instead, no differences between the group of
patients affected by the disorder and the control sample in the
critical distance attitude towards the negative stimulus; more
in detail, the activity of the prefrontal areas involved in the
cognitive regulation of emotions presents profi les very similar
to those of healthy subjects. The effects on the clinical level,
however, appear to be of extreme interest. If pharmacological
intervention is an important and necessary action in cases
of greater emotional intensity, the adoption of therapeutic
techniques capable of favouring down-regulation of states of
anxiety represents a decisive act in the modulation of early
warning typical of the emotional experience of patients with
this disorder. In any case, the small sample of the experiment
(17 patients and 21 control subjects) must be underlined, which
necessarily imposes an attitude of caution and reserve with
regard to the data that have emerged, which are nevertheless
promising and relevant for the future advancement of studies
on neural correlates and on the regulation of the emotional
structure in the disorder under examination [3,17].
Clinical profi les
With reference to the disorder in question, it should fi rst
be considered that in many cases there is an “avoidance style”
rather than a real personality disorder: the substantial difference
between the two conditions is determined by assessing how
deeply these affect the normal “functioning” and performance
of the individual in daily life. Think of a “bridge” between the
healthy and the pathological. The avoidance style is found on
the end of the healthy part, while the avoidance of personality
disorder lies on the unhealthy part [3].
The characteristics of the avoiding style of personality are
[1,3]:
1) Feel comfortable with habit, repetition and routine;
2) Prefer the known to the unknown;
3) Close fi delity to family and/or a few friends; tendency to
have the house as a point of reference (and consequently
go out little);
4) Sensitivity and concern about what others think;
tendency to an awkward and apprehensive attitude;
5) Excessive discretion and prudence in social interactions
6) Behaviour that tends to be reserved and self-repressed
around others;
7) Tendency to curiosity and attention considerably
focused on hobbies and pastimes;
8) Counterphobic behaviour successfully adopted.
The characteristics of the avoidance of personality disorder
are instead [1,3]:
1) Exaggeration with respect to their actual magnitude of
potential diffi culties, physical hazards and associated
risks in acting routine, but outside the routine;

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Citation: Perrotta G (2021) Avoidant personality disorder: Definition, clinical and neurobiological profiles, differential diagnosis and therapeutic framework. J Neurol
Neurol Sci Disord 7(1): 001-005. DOI: https://dx.doi.org/10.17352/jnnsd.000041
2) Total, or almost total lack of intimacy and confi dence
with individuals outside of close kinship; rejection of
activities involving signifi cant interpersonal contact;
3) Reluctance to get involved with other people without
certainty of approval; excessive sensitivity to criticism
and disapproval;
4) Fear of blushing, crying or anxiety in front of other
people;
5) Reticence in social situations caused by fear of saying
something inappropriate or silly, or not being able to
answer a question;
6) Tendency to perform less than one’s ability and diffi culty
in concentrating on one’s professional activities and
hobbies.
From DSM-V [1], the disorder under examination is
classifi ed as a pervasive pattern of social inhibition, feelings of
inadequacy and hypersensitivity to negative judgement, which
begins in early adulthood and is present in various contexts, as
indicated by four (or more) of the following:
1) Avoid work activities that involve signifi cant
interpersonal contact for fear of being criticised,
disapproved of or rejected.
2) It is reluctant to enter into a relationship with people
unless it is certain of pleasure.
3) Shows limitations in intimate relationships for fear of
being humiliated or ridiculed.
4) He is concerned about being criticized or rejected in
social situations.
5) Is inhibited in new interpersonal situations for feelings
of inadequacy.
6) He sees himself as socially inept, personally unattractive
or inferior to others.
7) He is unusually reluctant to take personal risks or
engage in any new activity, as this can be embarrassing.
From the point of view of differential diagnosis, the disorder
under examination differs from [3]:
1) Social phobia: the differences between social phobia
and avoidant personality disorder are subtle. Avoiding
personality disorder involves anxiety and avoidance
more pervasively than social phobia, which is often
specifi c to situations that can cause embarrassment
in public (for example, speaking in public, on stage).
However, social phobia can lead to a broader model of
avoidance and can therefore be diffi cult to distinguish.
However, research suggests that people with avoidance
disorder, in common with people with other social
phobias, over-monitor their inner reactions when
involved in social interactions. However, in contrast to
people with other social phobias, they also over-monitor
the reactions of the people they are interacting with. The
extreme tension created by this monitoring can justify
the hesitant way of speaking and the taciturnity of many
people with avoidable personality disorder. They are so
concerned about monitoring themselves and others that
producing fl uent speech becomes diffi cult.
2) Schizoid personality disorder: Both disorders are
characterised by social isolation. However, patients
with schizoid personality disorder tend to isolate
themselves because they are disinterested in others,
while those with avoidant personality disorder tend to
isolate themselves because they are hypersensitive to
possible rejection or criticism of others.
3) Other personality disorders may be somewhat similar
to avoidant personality disorder, but they can be
distinguished by peculiar characteristics (for example,
a need to be treated in dependent personality disorder
versus prevention of rejection and criticism in avoidant
personality disorder).
Finally, from the point of view of comorbidities, as we
have already seen, there are often anxiety and mood disorders,
depressive (up to the risk of suicide), obsessive and phobic,
precisely because of the common symptomatology. Such
comorbidities can aggravate the general picture, making it
more diffi cult to solve problems [18-29], especially in terms of
psychotherapy and for understanding the differences between
awareness of one’s clinical condition and the awareness of
wanting to obtain a benefi t by changing one’s dysfunctional
habits and behaviour [30,31].
Treatments profi les
The cognitive-behavioural treatment for avoidance
personality disorder works in the fi rst instance on the analysis
of dysfunctional, distorted and inaccurate automatic thoughts,
which are the basis of the disorder. These thoughts, once
identifi ed and shared with the patient, are challenged through
refutation and replaced with new, more functional thoughts.
For example, suppose that the patient strongly believes that
he or she is inferior to others and that others would like
him or her to leave the company where he or she works. The
therapist, using various techniques, questions the validity of
the thoughts by asking him/her the name of the people he/she
likes to spend time with him/her or other experiences he/she
has had fun with them. In this way the therapist demonstrates
that there are people who want to be with him and with whom
he has fun and that, in general, his fears and insecurities
in social situations are irrational and unfounded. This is a
simple example of a technique used in cognitive-behavioural
therapy called cognitive restructuring. Interpersonal cycles
are also shown to the patient, and thus how his personal
beliefs also infl uence others with reactions that ultimately
only confi rm the basic belief. The aim is to show him/her
possible strategies for dealing with the feared situations using
behavioural techniques. The analysis of interpersonal cycles
also makes it possible to improve the therapeutic relationship

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Citation: Perrotta G (2021) Avoidant personality disorder: Definition, clinical and neurobiological profiles, differential diagnosis and therapeutic framework. J Neurol
Neurol Sci Disord 7(1): 001-005. DOI: https://dx.doi.org/10.17352/jnnsd.000041
itself, which is fundamental for the continuation and success
of the therapy. For example, in this way the patient would
know that due to his personality characteristics he can
perceive the therapist as critical or judging, increasing the
sense of security if this happens and eventually sharing it in
real time and evaluating its truthfulness. Another therapeutic
approach for the treatment of personality avoidance disorder
is the interpersonal metacognitive therapy which, through
the narration of one’s own autobiography, attempts to solicit
the patient’s ability to differentiate between imagination and
reality, in particular in considering negative representations
of oneself with the other as hypothetical and not a mirror of
an objective reality; evoke alternative representations that
the patient possesses, but which are masked by the dominant
problematic mental states; promote new behaviours to replace
the usual ones; to form an integrated representation of oneself
that takes into account psychological contradictions and errors
in the patient’s reasoning, such as systematically noticing
hostile intentions in the other or strategies of the type “if I
avoid them, I certainly do not suffer negative judgement”;
to read the intentions of others with greater sensitivity; to
distinguish expected signs of hostility from actual ones and
to decentralise, that is, to assume the point of view of the
other not infl uenced by one’s own negative expectations.
Finally, various classes of psychopharmaceuticals, such as
tricyclic antidepressants, mono-Amino-Oxidase inhibitors,
selective serotonin reuptake inhibitors and dual serotonin
and norepinephrine inhibitors, as part of integrated therapy,
can be useful in reducing individual sensitivity to fear of
rejection, criticism and feelings of embarrassment and shame.
Benzodiazepines are indicated for the treatment of anxiety or
panic, nervousness and tension caused by having to deal with
social situations usually avoided. -blockers have been found
to be effective in managing the hyperactivity of the autonomic
nervous system (sweating, tremors, redness, etc.) that occur
when facing dreaded situations [3].
Conclusions
The recent interest of the academic world for this disorder
echoes the need for further investigation, especially in terms
of neurobiological and psychopharmacological elements, able
to better explain the internal relations with this disorder and
to fi nd the best strategic solutions to solve, according to a
multifactorial approach, the problems described by patients.
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Citation: Perrotta G (2021) Avoidant personality disorder: Definition, clinical and neurobiological profiles, differential diagnosis and therapeutic framework. J Neurol
Neurol Sci Disord 7(1): 001-005. DOI: https://dx.doi.org/10.17352/jnnsd.000041
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