Right now, about 6% of the world population and 9% of the U.S. population have been diagnosed with a personality disorder (PD). This means that over 450 million people worldwide suffer from 1 or more of the 10 types of PDs. PDs are a class of mental disorders which cause individuals to have unhealthy, inflexible patterns of thoughts and feelings about themselves or others. Because these psychological conditions can cause false perceptions of reality, culturally deviant behaviors, and distress for those whom it affects, PDs have the potential to lead to significant, adverse effects in many aspects of peoples’ lives.
Among the 10 specific types of PDs listed in the DSM-5, we will be focusing on avoidant personality disorder and antisocial personality disorder in this blog today. Even though these two conditions are quite different and part of different personality clusters — their similarity in nomenclature may lead to confusion about their clinical presentations and what their unique symptoms actually are. After all, “avoidant” and “antisocial” sound like they could be talking about the same thing, but these two types of PDs could not be more different.
What is Avoidant Personality Disorder (AVPD)?
Avoidant personality disorder, or AVPD, characterizes individuals who display patterns of extreme shyness, aversion to social interaction, and feelings of inadequacy — all stemming from a fear of rejection. AVPD patients feel inferior to other people in social situations, and at the same time, their chronic fear of rejection leads them to exhibit high levels of introversion and reservation. This condition may be difficult to diagnose because patients with AVPD use few words when they interact with people (because they don’t want to say something that will make them look “stupid”) and are very withdrawn about what they are willing to share with other people. It is also more commonly diagnosed in women compared to men. To summarize, these are some of the main diagnostic criteria that the DSM-5 has created in regards to AVPD:
- Avoidance of activities or jobs that involve large amounts of social interaction due to fear of criticism, rejection, or disapproval
- Avoidance of friendship unless they know for a fact that they will be accepted
- Restrictive in regards to intimate relationships due to fear of being shamed or mocked
- Absorbed with thoughts of rejection or criticism in everyday social interactions
- Reserved in social situations because of not feeling “good enough”
- Regards oneself as socially incompetent, unappealing, and subordinate to other people
- Avoidance of personal risks or new activities in fear that they will embarrass themselves
AVPD vs. DPD
Similar to those with dependent personality disorder (DPD) that we discussed in this blog post, the symptoms that AVPD patients experience are derived from fear like DPD patients. Because of this, both conditions are defined as Cluster C personality disorders, which means that they involve anxiety and fear. Their differences stem from the fact that those with DPD try to alleviate fear by doing everything in their power to cling onto those around them, while those with AVPD will do everything in their power to avoid others. In essence, those with DPD have a deeprooted fear of abandonment, while those with AVPD have a fear of rejection. Another difference is that the prevalence of DPD is quite low, making up about 0.5-0.6% of the population, while reports show that 1.5-2.5% of the population is diagnosed with AVPD.
AVPD vs. SAD
It was originally thought that AVPD might be a disorder that only occurs alongside social anxiety disorder, or SAD. SAD is a disorder characterized by anxiety and fear of social situations or performances. This anxiety disorder leads individuals to become fearful of being scrutinized, judged, or evaluated by others, ultimately leading them to becoming anxious in everyday situations. Things like eating in public, speaking in front of others, or participating in sports games can become stress-inducing and debilitating for patients, and like AVPD, it can make people ignore other social interactions and keep to themselves.
Research has since shown that AVPD does not have to co-occur with SAD, since roughly one-third of AVPD patients actually meet the diagnostic criteria for SAD. Both disorders can certainly present themselves in similar ways, with patients suffering from things like low-esteem and avoidance. However, there is a key difference between the principal causes of each disorder. On one hand, those with SAD experience deep feelings of anxiety related to social situations or social performances. They are fearful of the situations themselves, but they can still recognize that they are “equal” to those around them. Take them out of a social situation, and they are able to regain a sense of self-esteem, and most of their anxiety fades away. On the other hand, those with AVPD feel fear in social situations because they believe that there is something wrong with them that will make others reject them. They experience a deep sense of inferiority compared to other people, and they also assume that other people know they are inferior too, so they will avoid social situations to avoid embarrassment and shame. In terms of prevalence — 15 million, or 7%, of U.S. adults are diagnosed with SAD, making it a lot more common than AVPD, which only constitutes 1.5-2.5% of the population.
What is Antisocial Personality Disorder (ASPD) ?
Antisocial personality disorder, or ASPD, characterizes individuals who are impulsive, irresponsible, and display criminal behavior. Individuals with ASPD do not respect others and cause physical or emotional harm to those around them with little to no remorse. According to the DSM-5, there are a number of diagnostic criteria that individuals must recurrently display to be diagnosed with ASPD. In addition to an ongoing disregard for and violation of the safety and rights of others, those with ASPD must display three of the following:
- Failure to comply to laws and social norms
- Deceiving others for personal gratification or gain
- Failure to plan ahead
- Aggressiveness and irritable behavior towards others
- Can lead to physical fights or assaults
- Thoughtless disregard for their own safety and the safety of others
- Ongoing irresponsibility
- Unable to keep a job or financial obligations
- Lack of feeling remorseful
- No regard for how they might hurt or mistreat others
In addition to the list above, individuals must be 18 when they are diagnosed with ASPD, and these patterns of behavior must be ongoing since the age of 15 to be considered. However, research shows that approximately 80% of people with ASPD start to show symptoms before 11 years old. In comparison, the other 9 personality disorders are typically diagnosed when they are above 18 years old. ASPD is thought to affect between .6%-3.6% of adults, and it is three times more likely to occur in men than women. This condition is classified as a Cluster B personality disorder, which encompasses “wild” behaviors, resulting in intense, unstable emotional displays and erratic displays. Ultimately, it is one of the most undiagnosed and untreated mental disorders, and many people misunderstand what types of behaviors and symptoms it encompasses. Some more symptoms that exemplify ASPD include:
- Lacking guilt
- Blaming others for their problems
- Lacking concern or regret in regards to hurting others
- Unable to control anger
- Repeatedly breaking the law
- Exploiting others
- Behaving irresponsibly and recklessly
- Unable to sustain long-term relationships
ASPD vs. Conduct Disorder (CD)
Conduct disorder, or CD, is probably the most comparable disorder to ASPD. It is a type of mental disorder most commonly diagnosed in children, and it characterizes individuals who lack empathy for others, engage in behaviors that risk the safety of themselves or others, and have trouble following social rules. Sound familiar? Again, CD is typically diagnosed in children under the age of 16, and it is thought to develop from an impairment in the frontal lobe of the brain. This damage is thought to prevent children from learning what is negative and how to modify their behaviors to become more rational. Just to show the similarities between ASPD and CD, here are a few symptoms of CD that closely relate to ASPD:
- Stealing or breaking into other people’s property
- Destruction of property
- Physical cruelty toward others
- Initiating physical fights or assaults
- Staying out late without permission
- Disregard for leadership figures
- Lack of social engagement
- Unable to relate or care for others
- No remorse for their actions that harm others
Evidently, CD and ASPD are very similar mental disorders. In fact, they are so similar that the only real difference in their diagnosis has to do with age. If an adult is presenting symptoms and meets criteria for both CD and ASPD, they wil be diagnosed with ASPD. On the other hand, a child is more likely to be diagnosed with CD if they show symptoms for both disorders.
Now that both ASPD, AVPD, and their related disorders have been discussed, it is clear how different the 10 different personality disorders truly are. What is so difficult about personality disorders is that they can be very hard to treat in psychiatry. Many individuals with ASPD and AVPD may not reach out for help, and there are no medications that are solely designed to help treat personality disorders. Loved ones and those affected by personality disorders may reach out to medical and mental health professionals that can direct them to psychotherapy or CBT interventions to help manage symptoms. These types of therapy may help identify and modify aversive behaviors, and support is very necessary when personality disorders can be so debilitating to those who are experiencing them and to those around them.