To be so intensely alone that you can hardly find the words to describe how you feel. To doubt your every word and action, even your sense of who you are.
To have never experienced feeling truly known by another person. To fear others, yet long to connect with them. To yearn for the courage to take up space and speak out; to trust yourself and others enough to make your presence felt.
This is what people diagnosed with ‘avoidant personality disorder’ – one of the more common personality disorders recognised by modern psychiatry – have told us it feels like to be them. One interviewee said:
I feel like me as a person is not present. I feel like I do not know myself … I do not feel like I know who I am. That is kind of what I would like to know.
Many quiet people are there, but prefer to stay in the shadows. The girl in class who never raises her hand; the colleague who keeps to himself; the student who seems to never find his place in a group of friends. Shy but polite, perhaps seeming awkward or uncomfortable in social settings.
Some of these people are perhaps doing fine and are naturally introverts; however, a minority suffer with anxieties and depressive moods. They might seek help through therapists and in various clinical services. An even smaller number will be diagnosed with avoidant personality disorder. As well as craving connection with others, they feel inadequate and fear being ridiculed and rejected.
They’re sensitive to negative evaluation and criticism, feel incompetent, personally unappealing and inferior to others, as well as reluctant to risk engaging in new activities.
For someone to be diagnosed with this condition, these patterns of thinking and feeling towards themselves and others, and the social inhibition and withdrawal that follow, should be relatively stable across time and situations. These patterns must also be considered different from what the average person experiences in the relevant cultural context, and give rise to psychological suffering, including preventing the person from living his or her life the way he or she wishes.
The diagnosis of avoidant personality disorder was first introduced into the Diagnostic and Statistical Manual of Mental Disorders (DSM), psychiatry’s principal diagnostic text, in 1980. Recently, there’s been debate over whether it’s simply a more severe form of social phobia. However, it seems that avoidant personality disorder concerns more specifically problems with a personal sense of self, and of intimacy and openness in relationships, rather than with mere social avoidance.
The stories featured first a child, then a youth, and eventually a young adult who became increasingly alone, unhappy and bereft of comfort
Despite the many descriptions of avoidant personality disorder that exist, and the various psychological theories of why and how people come to struggle with these issues, we realised a short time ago that we didn’t really understand what it was like for people to live with avoidant personality disorder. One reason is that, when people with avoidant personality disorder go into therapy, the very challenges for which they seek help become hindrances for the therapy itself.
They struggle to articulate their experiences, and likewise fear hurtful reactions if they make themselves known. As a result, the therapist typically remains unaware of what’s taken place between herself and her client, believing that the client was satisfied with the therapy or, on the contrary, has given up on change.
The therapists themselves might become impatient or dissatisfied with therapeutic techniques that became stuck while their clients’ suffering continued.
As therapists ourselves, we’re writing partly from experience. It’s why – together with co-researchers with first-hand experience with avoidant personality disorder – we embarked recently on a research project to better understand clients with avoidant personality disorder from their perspective. What are their lives like, we wondered, and what is their avoidance really about?