Social Anxiety Disorder (SAD) and Avoidant Personality Disorder (AvPD) share characteristics, most obvious being the avoidance of social situations. At first glance, this may create difficulties in differentiation. Students have inquired why it matters, whether a clinician accurately differentiates SAD from AvPD, given it seems the work to be done is the same: to correct anxiety-driven, socially-avoidant behavior. What ensues is perhaps one of the finest examples of why the saying, “We treat symptoms, not diagnoses” is a foolish mindset.
It was discussed in my previous blog post, When Shyness Turns Ugly, that SAD is essentially a social performance-driven phobia. It is rooted in immense fear of saying or doing something that could cause shame and embarrassment, likely developing in reaction to an intense social scrutiny experience. SAD also tends to have a clear onset. It's successfully treated with exposure therapy, social skills training, and medications in the selective serotonin reuptake inhibitor (SSRI) category, like Prozac or Luvox.
The Avoidant Personality
While a core feature is social avoidance, like in SAD, AvPD is quite a distinct condition that requires a much different intervention. In brief, AvPD, at its core, is characterized by social inhibitions/avoidance that are driven not by phobic performance anxiety, but negative self-evaluation in comparison to others (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition [DSM-5]; Millon, 1996). In effect, there is a marked self-esteem component leading to social complications. The loveable Charlie Brown is the AvPD poster child.
Feeling they simply don’t measure up and are inept fools with little to offer, they project this onto others, assuming others view them as they view themselves. Just as they don’t like themselves, they assume others will not, either, and simply reject them.
This assumption is a defense, protecting them from having to put themselves out there and thus risk that potential rejection, which, in their mind, is bound to occur. Some people with AvPD possess such heightened hypersensitivity to rejection and judgment it borders on a characteristic of Paranoid Personality Disorder: reading hidden, deprecating meanings into innocuous statements. For example, a co-worker says, “Liling, I love that new dress!” Liling interprets the compliment as a sarcastic slight and thinks, “What’s that supposed to mean!?”
Additional devils in the details
As if a life driven by preoccupation about criticism and rejection was not hellacious enough, AvPD sufferers also appear generally anxious, tend to be profoundly unassertive, pleasure-deficient, and have an inordinate inability to accept compliments or see positives in themselves. It’s been my experience that, on occasion, their internalized frustrations find escape in a moment of hostility towards someone they feel is being critical. However, instead of relief, the person with AvPD deprecates themselves for the outburst and believes they’ve sealed their fate in appearing like a blockhead and slink away to the shadows to sulk.
Simplifying differentiation of SAD and AvPD
Though they share a commonality of social-based anxiety, AvPD is a more complicated beast than SAD. In contrast to SAD, a more “acquired condition,” AvPD, like most personality disordered situations, is rooted in pervasive core schema/beliefs about themselves and the world around them, that are learned early on and usually crystallized by age 11 (Shannon, 2016). The onset of AvPD is insidious from childhood, and the person is likely to be recalled as always having been “nervous,” “shy,” “introverted,” and perhaps self-deprecating. This inferiority and inability to feel special is correlated to significant emotional abuse in childhood where the person is often put down (Millon, 1996; Arntz, 2012).
Knowing this, therapists attempting to sort SAD from AvPD will do well to be extra-detailed in their history gathering. It is also helpful to survey a person’s core schema. If you plan to work with Personality Disorders, it may be helpful to learn about the Young Schema Questionnaire. Created by psychologist Jeffrey Young, it is a comprehensive tool for assessing core beliefs and their influence on the person's problematic behavior. The maladaptive core schema of those with AvPD tend to center around beliefs like “I’m boring,” “I’m incompetent,” “Nothing I do is as good as others,” and “People wouldn’t want to spend time with me because I’m not as good as them.”
In short, if there is an early history of emotional abuse, shyness, and self-deprecation present since a young age, and core schema as above, therapists should strongly consider AvPD with a corollary treatment plan focusing on the challenging and restructuring of problematic core beliefs. Readers may find it helpful to consult training by Dr. Jeffrey Young on schema therapy, and Dr. Theodore Millon’s Disorders of Personality for an exhaustive understanding of AvPD.
Clearly, there is a large difference between SAD and AvPD. It serves as an example to underscore the fact that, despite similar presenting chief complaints, it is foolish to not accurately assess different diagnoses. As illustrated, diagnosis allows us to conceptualize the nature of the symptoms, etiology, and purpose, which thus drives accurate treatment.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Arntz, A. (2012). Schema Therapy for Cluster C Personality Disorders. In van Vreeswick, M., Broerson, J., and Nadort, M. (Eds.), The Wiley-Blackwell handbook of schema therapy: Theory, research, and practice (1st ed., pp. 397-414.) Wiley. https://www.schematherapieopleidingen.nl/wp-content/uploads/2015/09/Arn…
Millon, T. (1996.) Disorders of personality: DSM-IV and beyond. Wiley.
Shannon, Joseph W. (2016, September 29). Reasoning with unreasonable people: Focus on disorders of emotional regulation. Brattleboro Retreat, Brattleboro, Vermont.