Clinical formulations of Avoidant PD
Clinical formulations and case conceptualisations are introduced in this post.
These are all generalisations and theories of how AVPD develops, not something that is supposed to be true for everyone with AVPD.
Shyness, shame, withdrawal & avoidance are defense mechanisms against embarrassment, rejection, humiliation and failure
Shame & fear of vulnerability/exposure of the self to others are interconnected
Avoidants feel ashamed about their perceptions of themselves as weak, incapable, defective
Shame a result of childhood experiences, and not living up to their ideal self
Shame is a defense mechanism designed to protect by perceiving others’ neutral or positive actions or words as negative, and by avoiding and withdrawing from social situations where they could be judged
High sympathetic nervous system (flight & fight) vs low autonomic arousal (fawn & freeze)
Results in hypervigilance (fight) against threats (being judged), shyness, timidity and avoidance (flight)
AVPD results from caregivers and peer groups’ rejection
Caregiver rejection is frequent and/or intense
Peer rejection reinforces the caregiver rejection, and reduces self-worth and self-confidence, creating self-criticism
Results in avoidance, hypersensitivity and excessive introspection
Hypersensitivity means they interpret small criticisms or even positive or neutral statements as rejections, and this lowers their self-esteem even further
Cognitive-Behavioural model
Avoidants fear being rejected so they don’t initiate or accept relationships
The conflict between their need for connection and fear of rejection is unbearable, so they withdraw
They also withdraw cognitively and emotionally from things that would make them feel uneasy or dysphoric
View themselves as incompetent socially and in school & work, as inadequate and different from others
View others as criticising, judgemental and uncaring
View criticism as being based solely on their perceived inadequacies
Use strategies like distraction, rationalisation, and excuses for when they feel sad and anxious
Avoidants grew up with relatively normal attachment processes, but their caregivers were very controlling when it comes to social image and reputation
Noticeable flaws were seen as embarrassing and humiliating
They were expected to be seen as perfect, and they were mocked and degraded if they weren’t
Results in hypersensitivity to rejection and judgement
Avoidants were likely irritable and fearful as babies and were likely slow to warm up to caregivers
View themselves as inadequate and fear rejection
View the world as unfair and criticising, but they still want connection
They need reassurance, but stay hypervigilant for judgement, and use fantasies and daydreams as escape methods
Tendency for catastrophic thinking
- From Sperry, Handbook of Diagnosis and Treatment of DSM-5 Personality Disorders (2016)
