Ep. 179- Avoidant Personality Disorder: When Fear of Rejection Consumes You
This episode delves into the silent struggle behind avoidant personality disorder, the crippling fear of rejection, and how treatment is finally making progress.
Are you or someone you love trapped in a cycle of loneliness and fear of rejection? Recent research and real-life case studies reveal powerful new insights about avoidant personality disorder, this deeply misunderstood disorder that’s likely more common than you think. Social avoidance is especially common now, as social media and remote life intensify those feelings of inferiority and rejection.
In this episode, Dr. Kibby dives into what avoidant personality disorder is, how it’s different from social anxiety, and how core beliefs of inferiority shape every aspect of life and relationships. She discusses how avoidant personality disorder stems from beliefs originating from unmet childhood needs, and how misguided coping mechanisms (e.g. withdrawing, self-criticism, and overthinking) perpetuate emotional pain.
Dr. Kibby breaks down the latest research, including a groundbreaking 2024 clinical trial testing cognitive behavioral therapy and schema therapy for this disorder. She shares compelling case examples, illustrating how understanding and gentle, sustained therapy can help individuals slowly soften their defenses, confront their fears, and build genuine connections.
If social rejection, shame, and feelings of worthlessness dominate your life or the life of someone you care about, this episode might explain why. Learn about innovative treatment strategies that target the core beliefs fueling avoidant traits and why patience and persistence are essential for lasting change.
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Dr. Kibby McMahon (00:00)
Welcome back, little helpers. Today I'm gonna talk about avoidant personality disorder. Someone with avoidant personality disorder has this chronic pattern of avoiding social interaction. It is a disorder that's defined by really deep feelings of inferiority, being less than or inadequate compared to other people, and
real sensitivity to any kind of rejection or judgment or criticism Even hearing this you're like, you know, who isn't like that? So I think that It seems like avoiding personality disorder seems to me like a more rare disorder
than the ones that I've always talked about like borderline personality disorder or narcissistic personality disorder. But actually, I think especially since the pandemic, avoidant personality disorder has really had a new heyday. ⁓ Actually, I've already covered this topic in 2022. When I was hosting with Jacqueline Trumbull, we did ⁓ an episode on avoidant personality disorder. And to our surprise, it was really popular.
but really highly criticized. ⁓ It gets pretty negative comments on Reddit and ⁓ on the platforms that it's posted on. And looking back, I totally understand why. With this podcast, I don't want to just riff on things that I believe or just make up. I really root whatever I'm talking about in the science. And
To my surprise, we didn't find a lot of research on avoidant personality disorder. So all we kind of had to offer and talk about was my personal experience treating avoidant personality disorder and then the research, which was just kind of like nothing. So we must have come across as just a bummer. ⁓ We might have come across like this is a really tough disorder for the people who have it and their loved ones and there's not a lot of good treatment options.
So probably our disappointment was evident through the actual episode. So I wanted to do this again. I wanted to be a little bit more positive and hopeful. And luckily there is a little bit more research on it. So that's something I could talk about. And I really think that maybe the pandemic, maybe the economy, maybe Gen Z, maybe the rise of social media, I don't know, but.
Avoiding life and being terrified of criticism and rejection and judgment is rampant. It's like probably at an all time high right now. So we all probably have traits of avoidant personality disorder now and we're struggling with it and we don't know how to break out of it. So in this episode, I'm going to talk about what avoidant personality disorder is, like how do psychologists actually diagnose it and how is it different from its similar cousin,
social anxiety disorder or social phobia. And I'll talk a little bit about the research that I found on what treatments actually help, including a case. I'll talk a little bit about my case, my experience working with this disorder, but also I found a case study on treating avoidant personality disorder with cognitive behavioral therapies, which I thought was fascinating. So I'll give hopefully a more optimistic ⁓ overview.
What is avoidant personality disorder? again, is a, someone with avoidant personality disorder is just always afraid of social interactions and relationships because they feel like they are inferior. They're worse than other people. So they have this really low self-esteem and they're terrified of any kind of rejection or criticism. ⁓ And because of that,
They constantly cope with those feelings by avoiding any situation that could possibly bring up ⁓ those kinds of things. So in order to diagnose the avoidant personality disorder, I'm actually going to read out the different criteria. And these criteria are traits. And as you can imagine hearing them, some people, know, lot of these traits are normal. You know, some people have them a little bit and some people have them a lot. And
It's a sign of avoidant personality disorder when someone has these traits in a pervasive, persistent, and impairing way. Meaning, if it's pervasive, they have this trait, they act like this everywhere in their life. At home, at work, with new people, old people, close friends, family members, everyone. Persistent means over a long period of time, so most of a person's adult life. And impairing, it gets in the way of the life they want to live.
So in order to actually meet criteria for avoiding personality disorder, you need to have four of the following. So the first one is avoid occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection. And that means someone who has avoided jobs, school, programs, activities, or tasks that have to deal with a lot of people.
As you can imagine, is so common now, especially, you know, like I'm a very social person, but I'm mostly home alone talking to a camera right now. So a lot of us are not dealing with a lot of people, but it's really the key point of why. Why is someone avoiding ⁓ having to deal with a lot of people? And that's because ⁓ they're afraid of being criticized or rejected. So if you're someone who
just doesn't like to talk to people, you're not a people person and you're totally cool with it, fine. But if it's driven, if you're avoiding those kinds of jobs because it's driven by, I'm not good enough, I'm gonna get laughed at, I'm gonna get criticized, and you shape your life around it, you choose careers that help you avoid ⁓ ever feeling rejected like that. That's one criteria. Second one is unwilling to get involved with people unless
certain of being liked. So that means avoid making friends or talking to new people or really interacting with anyone, really developing a relationship unless you know that you're going to be welcome or accepted. As you can imagine, that must be really, really hard, right? Like to, to, to, I think all of us when we ⁓
go into a new social situation or even old, you know, with people that we know. You don't know if people are to like you or not. You don't have that much control over the way people think about you. But if that stops you from interacting with them entirely, right, like not even taking the chance of meeting someone new, not even taking the chance of just spending time with someone and being like, OK, we're not we're not for each other, then that intense ⁓
avoidance is one of the traits and You know another way to tell that is if you don't know whether someone likes you would you ever make the first move? Would you ever talk to someone without knowing? Okay, I know they're gonna like me or they're gonna initiate first The other trade is show restraint with intimate relationships because of the fear of being shamed or ridiculed. So this is This is kind of the same thing right avoiding
avoiding rejection and criticism at all costs. And with new people on the outward-facing side, that's just, I'm not even gonna talk to new people, I'm not gonna interact, I'm gonna avoid parties, I'm gonna avoid networking, jobs. But this is, okay, what about the few people you do have in your life? Like the few friends or family members that you do have. Do you find it hard to be open?
even with people that you're close to, even with people who have demonstrated that they're trustworthy and they love you and care for you. And of course, there are a lot of reasons why someone might be afraid to be open, but the Void and Personality disorder trait is being afraid of being made fun of or embarrassed. So it's really about the fear of being seen as lesser than, right? It's not the fear that they're gonna hurt you or they're gonna be envious of you, but it's afraid of
They'll see how inferior I am and they're going to shame and I'm gonna feel so ashamed. I'm gonna be ridiculed for this. Okay, so you can't even be open with the people that you're close to. And then this is the next trade is preoccupied with being criticized or rejected in social situations. So this is interesting because I feel like a lot more people are doing this now because we have way less
in-person interaction. So I feel like that maybe it's just the people that I tend to work with in my practice, but there's a lot of this overthinking and ruminating over what do people think about me, right? If we are all in person like we used to be, right, you can kind of tell, you get more feedback faster, but I think now we're kind of on their phones talking to people all the time, being by ourselves in our heads and they're like overthinking, you know, did that?
or do those people hate me, blah, blah, blah, right? So we're overthinking a lot more. But this is spending a lot of time worrying about it. People with avoiding personality disorder think about this a lot all the time. Not just with new people, not just with like, the people I wanted to impress, like the cool people, but like...
every time they talk to their partner or even their therapist or their friends or new people. It's constantly worried, were they criticizing me? Did they like me? Are they rejecting me? It's just these kind of like preoccupied, obsessive thought loops.
And then another one is inhibited in new interpersonal situations because of feelings of inadequacy. And this looks like ⁓ the person is just quiet or doesn't show a lot about themselves and inhibits, like really closes down and shuts down when they're with new people. And again, there could be a lot of reasons why someone might
might be quiet with new people. And often if you say something like, ⁓ it's because, I don't know, I'm just more of a quiet person. I like to hear from the other person before I talk. That's not what we mean. People with avoidant personality disorder are quiet because they feel not good enough. They feel inadequate. It's this feeling of like, ⁓ if I spoke up, if I showed anything about me, it would reveal that I'm lesser than. I will be shamed.
I'll be rejected.
And then two more. One is view self as socially inept, personally unappealing, or inferior to others. This is one of the core things about avoidant personality disorder. It is a core belief that you are not as good or smart or attractive or worthy, really, than most other people. Now, is, in my opinion, it's healthy to...
understand that you're not the best at everything, right? Like that might be a little bit more narcissistic, but it makes sense that, you know, everyone who responds to this question, go, yeah, you know, I, when I went to this new school and you know, everyone was so smart there and I just felt like less, less than them. And I felt like inferior. That, that is more of normative response of like, you know, there are different situations where you're to feel differently about yourself and how you measure up to us.
But avoidant personality disorder is I feel like it is a core feature that they just believe they're inherently lower than other people all people most people Right, maybe there's one or two people. They're like, okay, maybe I'm better a piano than they are But but you you walk into a new situation and go I'm not as good as these people. I'm lower I'm less I'm less attractive. I'm inferior. They're just better people. I'm like
the Omega. All these people are the Alpha. And the last one is similar to the other ones but is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing. So this is interesting because it really what it looks like is someone who has a really narrow life who only
doesn't really go out of their comfort zone, right, is scared, has a lot of anxiety and really sticks to the people they know like them or the things that they know that they're good at. So they don't take risks. They don't try a new dance class. They don't try a new sport. They don't try pottery. They don't try going to a new school. They try a new job because, you know, a lot of people are like, ah.
of inertia, I don't feel like it, but with avoidant personality disorder it's I'm so terrified of being rejected or embarrassed that I'm not even going to take any risks. right, so those, so having at least four of the criteria that I just listed means you would get ⁓ the diagnosis of avoidant personality disorder and it has to be all throughout your life.
in all the different situations and different people and ⁓ in ways that get in the way of people's lives. Some people are fine with this. Some people are like, ⁓ yeah, I'm just not the best. And that's fine. I live a small life where I have only, you know, I'm like, I don't talk to too many people. I read books and, you know, I'm just in my introverted world and I'm cool with it. Then you don't have disorder. If you're cool with that.
That's great, but this is what I see as the impairing part with avoidant personality disorder is that people feel really lonely. Like they crave feeling loved and feeling like they belong and that they could be themselves around people. it feels like the people who have worked with this disorder have described it as, I feel like I'm in a fishbowl.
or I'm in a glass cage and I'm looking at all these people having fun, making connections, laughing, being silly together, and I just can't. I feel I might be there, but I'm so closed in, I'm so terrified of any risk of being made fun of or criticized that I can't even join them. I can't break out of this glass cage. So.
It's a really sad disorder. It's really, really sad. And I feel like us doom scrolling on our phone and being on computers is just not helping it. It's not letting us have different experiences that can change those beliefs of inferiority. So that is how we diagnose avoidant personality disorder. when I first learned about this disorder, was like, isn't this just like really bad social anxiety?
the DSM-5 criteria for social anxiety or social phobia, it's also called, is an intense fear of ⁓ one or more social situations where you might be exposed to criticism, rejection, or scrutiny. You fear negative evaluation and that fear is like what's interesting about
social anxiety is that sometimes the symptoms of fear bring up the fear too. So if you are afraid of public speaking and you're not only afraid of what people think of you, but you're also afraid of your own symptoms of fear. So you're like, I'm blushing, I'm shaking and people are gonna see that and they're gonna think I'm weaker, right? So like that kind of fear ⁓ doubles on itself.
These certain situations bring up fear anxiety, right?
And of course, this fear of rejection also gets in the way of the way you want to live your life. So as you can hear, it's very similar to avoidant personality disorder. Now what's the difference? As I talked about on the other episode on personality disorders, personality disorders is basically a fancy, and I hate that term personality disorders, but it's more of this chronic pattern. It's like, what do you like all the time with everyone? With...
regular mental health disorders, it's more about ⁓ like a syndrome, like a certain time period where you're having these symptoms or certain situations, right? So for social anxiety, the understanding is that it's certain kinds of social situations that bring up these fears. Like public speaking is a common one, eating in front of others, meeting new people, social networking, right? So sometimes it's like those situations
definitely bring up these fears, but not all of them, right? There might be some situations that you feel like these people really know you and you feel really comfortable, right? Then if I hear that, like, ⁓ that person might have social anxiety, not avoidant personality disorder. So it's really like, what kinds of social situations, how pervasive is this? How many social situations bring up this fear of rejection? And then,
I also found in the research that both can be very severe. So it's not a matter of like which one's worse, but it's almost like people with avoiding personality disorder really have this belief in themselves that they are inferior. They're broken, they're worse, they're bad. They are shameful. They're embarrassing. Like they believe they have such a low self-esteem.
People with social anxiety disorder often do have low self-esteem. They're like, yeah, I'm, you know, like, I'm really nervous when I do public speaking. I'm not very good at it. And I'm just, as soon as I see all the faces, I'm terrified, right? But avoiding personality disorder is like, I'm just a worse person and I'm terrified of anyone actually seeing it.
And as you can imagine, people with avoidant personality disorder are more depressed. It's so impairing, they have such a narrow life. They decide what jobs they're gonna get. They never try anything new. They might really wanna move to a new place. They might wanna change jobs, but they just can't because there's always that small risk that if you do something new, interact with new people, they might not like you.
They might see the badness, the inferiority, and they might embarrass you. So it's a really gripping, a really deep-seated belief in avoiding personality disorder.
To give an example of what this looks like, I've worked with a couple of people with some avoidant traits, which is getting more more common. But I remember there was this one person, I won't give identifying information, so kind of muddle the details. there was someone who I worked with for about six months, maybe a little bit less.
in cognitive behavioral therapy and this person was a lovely person. It just so kind, so talented, so strong and I just had so much admiration for this person that it was so confusing to just hear the opposite from them about themselves.
This person was...
⁓ They had their own family, they had a spouse, they had kids, they had friends, they had a job. Actually, if I'm thinking about it now, ⁓ I would say that at some point it was probably low severity because that person was able to make all those connections. People with severe avoidant personality disorder are just like never leaving their rooms, right? ⁓ But this person did have a life. ⁓
But every week, every single week, we'd talk about how they could not stop thinking about an incident during that week that made them feel rejected or criticized. ⁓ At first I was like, okay, this seems like normal, like social anxiety, I get this, this is, you know, like, ⁓ makes sense, I validate and like kind of talk through it. And then we might have...
these breakthroughs. Like we had a couple of breakthroughs where it was like, wow, they could really see that this is what their mind was doing. And maybe, maybe the world isn't as bad as they were thinking. I mean, they were just drowning in it all day, every day, thinking about this one thing that someone said that made them feel hurt. And then they'll be like, ⁓ this is my anxiety. ⁓ Maybe that person wasn't.
being mean to me. ⁓ And then the next week they would come back and it was the same thing. Even we would talk about that same situation and it was like that breakthrough disappeared. So I was like, huh, this is an interesting, usually people who are new to therapy like, know, can sometimes, you know, learn new things, start to see things in a different way. But this person was like,
It was like, it felt like a hamster wheel. I felt like, okay, we're back, we're back, we're back. This is the same. Everything was being put in the same machine. ⁓ For example, one ⁓ of their doctors had mentioned, ⁓ you know, it seems like you have a little anxiety. And that was the topic for weeks about...
What did they mean by that? They were seeing less of me. How could they say, you know, they saw me as weak. How could they give me that diagnosis? And at first, you know, like, you know, I was doing my best to validate and be like, yeah, that must be, you know, that must feel terrible to kind of get a diagnosis. But it started to get really...
really preoccupied, that word that in the diagnostic criteria was really there. We were talking about the tone. Like, that doctor said it like anxiety. And even that tone, I could tell that they were saying that I'm a difficult patient. it was like, this was what this person was thinking about for like three weeks straight. ⁓
We couldn't even get to a place of, you know, maybe they're telling you this because they wanted to help you or they thought you already knew. Like no other possible explanation except for that doctor was was pointing out how inferior I am, how weak I am. ⁓ Which broke my heart, really, because I was like, my gosh, if we if we even got more help with your anxiety, you'd be so much happier. It was so it was so sad. It was so sad to watch.
this person look at their life, at all of the evidence that I could see that they were loved, they were accepted, they were cared for, and they were like, you know, that person looked at me this way and that's a sign that they hate me. My kids don't even like me. They don't respect me. They know I'm a worse parent than my spouse. it just, constant, constant.
And their life was so small because of it. were just aching, aching with pain talking about watching people, you know, after school and stuff like that, like watching other parents be friends, making relationships, ⁓ showing parts of themselves to other people. And...
That person just felt so much pain for being so alone. Like feeling like they were in a fishbowl, like behind glass watching everyone connect while they're completely alone. And it felt even more painful for them because they're around people. ⁓ They're around their partner and their kids. It was so sad. I'm...
I made a mistake in ⁓ that case and I talk about that, I talked about that in my interviews, I regret it to this day. I did not understand how deep avoidant personality disorder really was, that depth of core belief. At that point, I had only worked with people with social anxiety disorder and I'm very proud to say that when I work with people as coaching or clients,
I really care about everyone I work with. ⁓ Even people who are like difficult. There's just something in me that like just loves what I do and so I just make a connection and I understand them and everything. And I, for the most part, with people with social anxiety, ⁓ I get to a point where they trust that I'm on their side. It's not all the time, right? There's times where I make them feel rejected or criticized, right?
I'm a human being and that's really good meat to work through in therapy. And I really thought I had that with this patient. I was like, okay, they know that I'm here. They know that I care about them. They know that I'm doing everything. And that was the thing too. I was really trying to show them that. And that felt different than other patients. Other patients with social anxiety like...
I don't feel as gripped by that. Like I need to prove that I care, that I actually accept you in order for any of this session to go well. ⁓ So I was really like proving my care. ⁓ And I remember they were having a really hard time one day. They were really like, no one cares about me. No one loves me. Everyone hates me. And I made the mistake and I invalidated that person's feelings. I was like, ugh.
It must feel so hard, but you know, I'm pretty sure your partner sounded like, you know, they said these things that, they said, I love you. Like, do you feel that? And they're like, no, they're lying. They're just with me because they feel bad for me, right? Like I'm lower, I'm not worthy. And I was like, you know, I really care about you. I love working with you. I think you're a great person. I really laid it on thick.
And I remember they just sat there slumped and sobbing and they were like, no, you don't, you don't actually, ⁓ you're lying to me. You see me as worse than, and I was just arguing against it. So I made the mistake that now I teach everyone, ⁓ don't, when someone's really dysregulated, don't argue about what they're saying, because they're saying, I'm just lonely. And I was trying to be like, no, I'm showing you that you're wrong, that you're not unloved. I love you, I care about you. ⁓
And they were like, you know, I'm gonna stop therapy because this is too much. And I think about them all the time. That was one of my mistakes. ⁓ Well intentioned, but that is what happens with people with avoidant personality disorder. And this is what the experience of loved ones that I've talked to, people who are partners or friends of people with avoidant personality disorder.
They feel, the loved ones feel rejected a lot, ironically. Same with social anxiety disorder. When you are afraid of rejection, you really tend to push people away. You tend to reject them first before they can reject you. That's a real sign of fear, of rejection, and a problematic way of coping with it. It's like, if you're gonna reject me, I'm gonna reject you first. So actually people who struggle with, I'm so afraid of getting rejected,
they actually push people away a lot. So people with avoidant personality disorder, their loved ones feel lonely. They feel like they have to prove their care to that person and that person just disappears sometimes. Sometimes stops talking to them, ghosts them. And then the loved ones are left being like, what did I do wrong? What happened? ⁓ Not realizing that the person with avoidant personality disorder ⁓
just read it, read criticism or rejection in something that happened and it was just so painful, they pulled away entirely. So it, you know, I said this in my first episode on this and I still say it now, it's really hard for both people. It's really lonely and it's really hard to break out of.
So that's really clinically, that's how I can tell avoidant personality disorder with social anxiety disorder. Sometimes these core beliefs about yourself feel like the roots of a tree. And no matter what branches, flowers, ⁓ leaves spring out from the roots, it's all that root, right? These are core beliefs. I'm lovable, I'm unlovable, I'm inferior, I'm better than other people, I'm special, right? All these...
different beliefs about who you are in comparison to other people and your place in the world. people with social anxiety disorder might feel insecure sometimes, but they don't have as much of the core belief that I'm bad. I am inferior as people with avoiding personality disorder. And it just comes out everywhere, right? I'm bad. I'm less than.
So what are we gonna do about this? This is, ⁓ I feel like we are in a time that is ripe for developing a Void Impersonalities disorder. my God, I I thought I had a relatively decent sense of self ⁓ with some issues, but with COVID and us working remotely and being less in person and being alone and being on your phone.
where you're doom scrolling and looking on social media where it's designed to make you compare yourself and make yourself feel inferior, right? Like consumerism is all driven by making you feel like you have less than what you need and you can get what you need by buying whatever they're selling, right? So you picture beautiful pictures of people and people essentially bragging online. If you're alone and just seeing other people brag ⁓ in your hand, you're gonna feel worse.
than everyone else and you're going to avoid situations that bring up the risk of rejection and criticism. So I feel like the world is really ⁓ nurturing the avoidant personality disorder traits. So if you notice this in yourself or someone else, like what do you do about it? So.
If you are a loved one, if you love someone with a voting person, I swear to if you're like, yeah, I feel like I know someone who no matter what they think that they are just the worst and they think that no one likes them and no one cares about them. And it's just like draws into themselves because like it's just closed down draws in. ⁓ Don't do what I did. Don't keep pushing about, know, I like you. Don't try to reassure them over and over.
Stay steady and validate their feelings. This must be so painful. This must be so hard. And you have to go really slowly. So.
I hesitate to say this because this might put a lot on the loved ones, but
know that they are like terrified inside and if they ghost you or if they you know they kind of disappear they shut down and then ⁓ the thing not to do is to run after them and say like you know why why are you doing this you know like piling on more negative evaluation or like you know kind of criticizing what they're doing so just stay steadying yourself
say I love you, you feel comfortable, I'm here to talk. And then in the case, this is the case, this is what we were taught for when we have patients with a personality disorder. When they come out of their shell and just are able to like remake contact with you again or, you know, reengage.
your first instinct is going to be like wanting to talk about it, right? Like, why did you ghost me? That was so painful. Are you okay? What's going on? Right? To really address it. Normal. That might be a little bit too much for them. That might be what they're afraid of, right? They avoided a situation that was scary, they withdrew, and then they feel bad about themselves for it. They're like, well, see, this is why I'm broken, blah, blah. And so...
having to confront, re-engage with people and getting questioned about that and the way they behave, it's going to be really, really intolerable for them. So you might just, you know, kind of chill on that when you, when they first start talking again, just like go slowly, you know, like just be kind. You don't have to overly reassure them, but just, you know, sit back in yourself. That's what I wish I did with, with that patient. I wish instead of,
rushing in to pull them out. Like it felt like it felt like that person kept like withdrawing into themselves and I had to go in and pull them out. ⁓ But don't. I wish I stayed steady. I wish I just stayed this compassionate, open presence and let them slowly ⁓ come towards me. So that's something to do for loved ones. But
There is some new interesting research that I read where there were a little, compared to when I first did this episode, there were a couple more clinical trials ⁓ testing treatments for avoidant personality disorder. And ⁓ what has been mostly tested was a cognitive behavioral therapy. That's a broad term, right? But cognitive behavioral therapy for any kind of like social anxiety, it's usually,
is usually addressing the avoidance, that's the behavior part, like instead of pulling away from something, approach it, right? Face your fears. That's really CBT for most kind of anxieties is face your fears. Why? Because when you face your fears over and over and over again, it gets less scary. That's just from habituation, the feeling that you get used to something.
Right? So if you were to watch the same horror movie eight times, the first time is going to be terrifying. The eighth time you're going to be like, this again. Right? So that's habituation. ⁓ The anxiety just naturally goes down when you're exposed to the same thing over and over. And the key part there is that you're learning that this is not as scary as I thought. This is not as dangerous as I thought it would be. Or if it is, now I know how to cope with it.
Right?
if I give a public speech, if I speak publicly, I'm gonna stumble over my words and everyone's gonna see that I'm stupid and they're gonna make fun of me. Right? And so the treatment for that,
cognitive behavioral treatment for that is, unfortunately, practicing public speaking or imagining it or just putting yourself in that situation over and over and over again. Even small pieces like talking in front of a therapist or talking to in front of like two people, right? But like slowly, slowly until like the eighth time you watch the horror movie, it gets boring. You're like, you know, yeah, I did stumble and I learned that, you know, it was fine. No one made fun of me, right? Or I...
I didn't stumble as much as I thought, or my hands are shaking, but no one noticed, right? So ⁓ CBT for social anxiety is usually like exposing yourself to situations that usually scare you and learn from it. Learn a different way of coping. Learn that it's not as dangerous as you thought it was going to be. So there are some research studies showing that cognitive behavioral therapies are very effective.
Not very effective, but effective for avoidant personality disorder. Now, there is a really cool study. ⁓
I can't even say the last name, but I'll link it to the show notes. But there is a randomized control trial that was published in 2024, I think it's from the Netherlands, in Journal of Anxiety Disorders, that compared group schema therapy versus CBT for patients with social anxiety disorder and avoidant personality disorder. So these people...
Those could not, just avoided rejection at all costs, right? These poor people. And what's interesting is that there were no significant differences. Like both group schema therapy and group CBT were equally effective. ⁓ But what was really important is that people dropped out less in group schema therapy. So people liked it more and stayed in it.
The downside is that the people got better while they were getting treatment, but those benefits weren't seen as strongly in the follow-up. So they believe that for both someone with a void in personality disorder, you need a lot of treatment. You need a lot and longer treatment, right? Because it's such a core belief that
you really need a lot of sessions over a long period of time for the person to learn that they are not as inferior as they thought.
And for reference, in this study, they did 30 ⁓ weekly 90-minute sessions, right? So, and then followed by three months of no therapy. So they felt like that was not enough. The researchers were like, great, CBT and schema therapy works, but we probably need more. We probably need more sessions.
and I'll explain what schema therapy is all about. It's really interesting. So I'm gonna have a look here, schema therapy. So ⁓ schema therapy is a cognitive behavioral therapy that kind of pulls in some stuff from other things. It feels a lot like ⁓ IFS, internal family systems, but schema therapy was developed as a treatment for personality disorders.
originally mostly for borderline personality disorder and the basic idea is that Young, who's the name of the guy who came up with it, Young said that we have ⁓ needs in our childhood that need to be met and if they're not met then we compensate in different ways. It kind of shapes our core belief in ourselves and we compensate by
⁓ You know either like doing it try to get it too much in our life or running away from it. So the The whole therapy is about really understanding these different modes that are brought up when these like You know unmet needs are triggered and then really understanding them and working with them.
So according to schema therapy, avoid impersonal disorder. That core belief that you're bad and not worthy and lower ⁓ is usually because your needs of being emotionally supported were not met. You were emotionally neglected. Your parents or caregivers didn't listen to you, didn't see you, didn't meet your needs, didn't treat you as someone worthy, right? Most of the time they've also just been like.
criticize, like a harsh punishment, right? So the need that wasn't met is emotional support. And avoiding personality disorder is a way to cope with that feeling, with that unmet need. So in this book, for example, avoiding personality disorder, the main modes are a lonely, vulnerable child mode. So this deep feeling that I'm alone and I'm a weak inferior.
scared child. A punitive parent mode which particularly induces feelings of guilt. So that is usually, you know, probably what they brought in and learned from their parents who are critical or even just the way of coping. ⁓ That feeling like, like that internal inner critic, right? That's, that's like you do, you did this wrong. You, didn't do enough.
I don't what that feels like. But this always feeling of like I'm being punished inside, right? And avoidant protector mode is another part of avoidant personality disorder. And that is it helps patients distance themselves from inner needs, feelings, and thoughts. So in avoidant personality disorder, feelings of ⁓ loneliness and even like, ⁓ you know, I feel rejected. Like any of that, the pain of normal social interactions and relationships is so
painful is so uncomfortable and intolerable that their avoidant protector mode is a coping mechanism to protect them from that, right? It makes them go, uh-uh, that feeling of being objected is so painful. I'm just going to avoid thinking about it, avoid feeling it, avoid any situation where that person might not like me, right? So it really like shelters them from discomfort. And the compliance surrender mode.
which relates to the typical submissive behaviors of these patients where they subjugate to the needs and ideas of others. this is like, I care about being liked so it's a people pleasing. I care about being liked so much that I'm just going to ⁓ be totally, ⁓ submissive, right? Ignoring my own needs. I'm here just to, you know, I'm inferior and I'm just here to make you happy. And if not, I'm gonna run away.
So that's how schema therapy would think about avoiding personality disorder, right? You have this vulnerable child, lonely, vulnerable child, and all these different modes to protect them from it. Avoiding being hard on themselves, ⁓ being submissive, right? Just like avoid, avoid any kind of punishment. Avoid getting in trouble. I feel like that's probably it. Like avoiding personality disorder is an intense need to avoid getting in trouble socially.
So while cognitive behavioral therapy would work on, what are these beliefs that are not serving you? That everyone hates you, that ⁓ new people are gonna make fun of you, laugh at you. Well, let's expose yourself to new situations with new people and learn to habituate, right? Like learn to, know, practice makes perfect or facing your fears. ⁓
or learn how to cope with it. they reject you, like, let's learn how to tolerate it and how to work with it, how to cope with feeling like someone doesn't like you. But schema therapy is a little bit different. So it's still focusing on all those things. But there's a little bit more.
It's probably, I could tell why it's, people didn't drop out as much because cognitive behavioral therapy is like, you know, like just put yourself in those situations that scare you and then, you know, you'll get better, which nobody likes doing that. It's really effective, but no one likes it. But schema therapy is a little bit more about, you know, let's notice all these different modes. Like when does your avoidant protector mode come up?
and let's notice what it's doing, notice what it's making you do, let's validate it, let's be soft and compassionate that you have these different modes that protect you, and let's learn to do something different.
In schema therapy, you might do some imagining old painful memories when you first felt like you were the invisible lonely child and really picturing it and then a little bit of limited re-parenting, right? The therapist is there and you're there to kind of learn a new way of addressing this mode of yours, right? Like I'm a lonely child, I'm not good enough.
And instead of really developing that punitive parent mode of like, yeah, you're not good enough, you are wrong, blah, blah, but learning, okay, maybe I can understand that I was scared at the time. what would it be like if I were gentle to myself? What if I was supportive? What if I were compassionate and protective? So relearning how to parent yourself inside, learning different ways, different modes of
coping mechanisms for these painful feelings. So it's a little bit more about the relationship is a little bit more experiential. Like you might do chair exercises where you like the patient will sit and look at a chair and imagine different parts of them are there like imagining themselves as a lonely child sitting in a chair. And what would you say to that? You know, so it's it's a little bit more about like these inner parts of you and working with them with gentleness. Not that CBT is not gentle, but
CPT is a little bit more like, yeah, let's just expose yourself to really scary situations and then, you know, go for it. So you can imagine that the group schema therapy ⁓ didn't have as many dropouts, it's a little softer. I mean, the study is even interesting because it's both group cognitive behavioral therapy and schema therapy. So people who probably did the study have enough, I don't know, enough of a motivation to like,
be in a group doing therapy, which I can't imagine anyone with avoidant personality disorder really finding that comfortable. But you know, like that's probably a good thing if they're able to do group schema or group cognitive behavioral therapy. You already have the willingness to do something to get better. So that probably was a really good sign of people going into these treatments. And I really love, I'll also link this case study that I found. ⁓
describing what it would be like to do a schema therapy with someone with avoidant personality disorder. And this case was really interesting because it sounds a lot like what lot of Gen Z people are struggling with. This 22-year-old female diagnosed with avoidant personality disorder and depression.
This person struggled with feeling depressed, difficulty eating, difficulty falling asleep, really tired, and feeling really hopeless and helpless and wished that they weren't alive, right? These passive death wishes. Just like, just don't want to be here. And probably more common, she's spent most of her days in her room and spent a lot of time on her phone.
and felt really terrified to talk to other people because she always felt inferior to others. So that was the case that's described. And this therapist who wrote this,
noticed that the different modes that we're talking about, when we talk about, again, schema therapy and modes, like the different, ⁓ I don't know, it's kind of like a persona, a different way of being, right? The way of, know, ⁓ the feelings and your behavior and what you tend to do in response to something. So ⁓ they had
these core beliefs about herself were driven by feeling abandoned and emotionally deprived, not supported, right? So that was the need that wasn't met in her childhood. And the way she coped with that was subjugation, like being inferior, right? Just like, I'm worse, I'm putting my head down, I'm submissive. And the other parts of her were unrelenting standards. So.
This perfectionism, like you can't mess up. If you do anything that is a mistake or ⁓ not perfect, then people are going to laugh at you. People are going to reject you. You're going to get canceled. ⁓ And she also had others like social isolation, defectiveness, mistrust. She didn't trust anybody because she was like, I'm so defective. I'm so... ⁓
broken and worse that I just need to be alone. I can't be around anyone else.
So the interesting part about this case is that, kind of like a lot of people know,
this case called Miss A, was really afraid of emotional overwhelm. So she said things like, I'm scared if I feel too much, I'll not be able to manage that. And I cannot feel weaker. So the idea that she would feel uncomfortable was just out of the question, was unbearable. So she felt a lot of like, I can't cope with my own feelings. And
The thing that the therapist noticed was that she had a strong avoidant protector mode and a self-soother mode. So that is the interesting thing about phones and avoiding personality disorder is that she, ⁓ in order to protect from these feelings of emotional overwhelm, she avoided everything. She stayed in her room, she didn't talk to people, she didn't take risks or anything like that.
But not only that, not only was she just avoiding, but she was self-soothing with being on her phone. ⁓ So feeling like she was interacting with people when she was just looking on social media, right? And self-soother modes, that's usually more of like an addiction. ⁓ Like a self-soother mode is found in a lot of narcissistic personality disorder where they are self-soothing with like drugs, you know, like in alcohol, right? So like soothing people feelings with something.
So she was avoiding not seeing people not taking risk and not making relationships, but also was like soothing those feelings with like false social interaction. ⁓ And those are all working together to shield her from her distress.
So that's what the therapist said was really, really hard because he's imagine those modes are gonna be really loud in therapy, right? You're talking about things that are really painful. You're opening up to someone new, right? You're being intimate with someone in therapy and she would apparently her avoid and protect your modes would come up and that would look like avoiding
know, topics or looking away or just shutting down in sessions. And that's really what I experienced too with my ⁓ patient with avoiding personality disorder. There were some sessions where we barely could talk because they were just inside themselves. They withdrew. They shut down. ⁓ So...
this case describes that, you know, really working with these modes and like really looking at each mode and saying, hey, avoidant protector, like, thank you for what you do. Thank you for trying to protect me from pain. I understand. However, what if we, what if we soften, what if, what if we, I don't know, I'm making this up because it's not even in here, but, replacing that with
with another kind of coping mechanism, like with kindness and a little bit more openness. ⁓ And really being gentle and kind with all these different parts of her. And then she started to be able to let her guard down, so to speak.
The other interesting part about this case, which I feel like I'm also seeing this a lot too, is the patient experienced her emotional overwhelm as fatigue. She was saying, when I'm stressed, I'm not able to move. I feel so fatigued and exhausted that I'm unable to get up from my bed in the morning. Now I've seen people talk about this as like functional freeze. ⁓
which makes sense, but that in therapy can be really tough because it makes the person really passive, right? They don't want to engage. They're just like, I'm so tired. I can't even, right? So not only is it tired, but it's also experienced tired and like passive, right? I'm not going to engage. And the therapist explored this with the patient and they described it as the wall, this feeling of the wall.
So the wall is a new mode that they made up, and that is basically avoiding to protect from pain, from judgment, criticism, failure, and an angry passive child mode that's basically angry and protesting that people are not taking care of me or noticing me, that I feel lonely. So it's this...
frozen overwhelm state that was like, that has a little bit of anger and a little willfulness, a little bit like the patient described it as exhaustion, but it's exhaustion that's like a no, I'm avoiding, I'm blocking myself off from pain and protecting myself, but also like I'm being a little angry that this is so painful. So noticing that working with those modes was
the really the key that changed this case and ⁓ she got a lot better.
So for people who have avoidant personality disorder, that's an interesting thing to keep in mind when you get treatment is to work with, I mean, it takes time, of course, but working with a therapist, I'm gonna work with a lot of painful feelings.
but maybe you could go slowly and maybe you can ⁓ learn over time to talk to yourself in more compassionate, gentle, healthy ways than the hard, you're inferior, you're not good enough, you're bad, everyone's gonna laugh at you. Like really slowly building up new ways of parenting yourself, right? And new ways of dealing with pain ⁓ could be really helpful. And knowing that
suppressing emotions and blocking yourself from the risk of getting rejected is your way of protecting yourself. But it also prevents you from really being yourself around people. like, we make relationships and when we develop intimacy with someone, it's always a risk. There's always a risk involved in getting close to someone.
There's a risk that they won't like a part of you. There's a risk that something will happen to them. There's a risk that you don't like part of them and the risk that they leave, right? Like forming a connection is scary because you are really going out of your comfort zone and risking a lot of things that could be really painful. However, those risks are necessary. They're necessary to stop being so lonely and actually making connection, right? So...
putting yourself out there is part of how to heal, but if that's so hard because there's so many things inside that are protecting you from that pain, then cognitive behavioral therapy or schema therapy can be really helpful. And it's gonna take a long time. All these studies that I saw were like, know, lots and lots of sessions and a lot of slow patient work. So I will maintain.
what I said in my first episode that Jacqueline and I said were that this is a hard disorder and it's hard to treat because ⁓ my god like personality disorders in general are hard to treat in therapy. You have people who have trouble with intimacy and relationships and you have them sit down in front of a new person and tell you know your deepest darkest secrets. I can understand why the treatment for mental health is hard for people who are afraid of you know intimacy.
So it's a hard, it's a really lonely, painful disorder for both the person with it and their loved ones. But I can say that there is more research showing that cognitive and behavioral therapy can be effective. You just gotta stick with it. So that's all I have to say about avoidant personality disorder. I wanna hear your thoughts about that. If anyone has it, I want to hear from you. You could always...
comment in Spotify and YouTube. I've seen some people comment, so that's amazing. I love talking to you guys. ⁓ And I got some requests for other personality sorters. I got a request for, I think, schizoid personality disorder and one on ⁓ paranoid personality disorder. So I will be covering those in upcoming episodes. And if you have any other requests, let me know. Otherwise, if you give this podcast a five-star rating,
Apple or Spotify, that would be awesome. See you next week.