Did the DSM Get it Wrong?

Is Avoidant Personality Disorder the most recently created personality disorder? Technically, it was introduced in the DSM-III in 1980, along with three other “new” personality disorders: narcissistic personality disorder, schizotypal personality disorder, and borderline personality disorder. However, the origins of these three date pretty far back in comparison to Avoidant Personality Disorder, which was only coined in 1969 by Theodore Millon¹. So that begs the questions - Why is this showing up so late in the game? Is this actually a separate personality disorder? 🤔

The History of Avoidant Personality Disorder¹

In 1969, Theodore Millon came up with Avoidant Personality Disorder, focusing on the process of active detachment from psychological pain and social relationships (in contrast to passive detachment in the schizoid). Millon highlights historical theory that intertwines with schizoid personality dynamics, until he separated them in 1969. A prominent concept that Millon describes is Kretchmer’s hyperaesthetic part of schizoid. Kretchmer described a core schizoid component (unsociable, quiet, reserved, serious, eccentric), then a continuum in which the schizoid can drift back and forth in: aesthetic (insensitive) and hyperaesthetic (overly sensitive)^{2 1}. Millon separated the hyperaesthetic aspect into what is now Avoidant Personality Disorder…which elicited a lot of controversy.

Controversy Surrounding Avoidant Personality Disorder

After the introduction of Avoidant Personality Disorder in the DSM-III, theorists had some interesting arguments in The American Journal of Psychiatry. Livesley et al. (1985)² argued against avoidant personality disorder as a separate, standalone personality disorder, calling out Millon for pulling out hyperaesthetic from Kretchmer’s full schizoid theory. They also quoted Gunderson…which I think is a pretty clear, powerful comment on the topic: “In the absence of any clinical, empirical, or even widely accepted theoretical rationale for such a distinction, it is difficult to understand why this category [avoidant personality disorder] was established.”

Millon³ responded in the journal in 1986, noting that Livesley et al.² were not members of the APA taskforce for the DSM, so they’re missing data…a fair, but egocentric point. Then Millon³ argued that he conceptualized avoidant personality disorder first, then figured out Kretschmer’s hyperaesthetic fit with avoidant…which is….suspicious. It could be true, but for myself, I’m not buying it due to the snobbish undertones in Millon’s writings.

Then in 1986, Akhtar⁴ responded to Livesley² with my favorite argument! He noted that avoidant and schizoid should be separated, but not for the reasons that Millon³ proposed. Instead, Akhtar⁴ focused on defenses, with avoidants using higher level defenses like repression, symbolism, and displacement, while schizoids tend to use lower level defenses such as withdrawal into fantasy and splitting the self off from their own needs and the world. He also argues that schizoid and avoidant personalities are structurally organized in a different way, and that avoidant personality is a personality where fear, anxiety, and phobic processes have become one with the person, intertwined with who they are (ego-syntonic)…just like depression could be a depressive personality or OCD an obsessive-compulsive personality⁴. He was essentially saying that avoidant personality is a phobic character⁵ (According to the PDM-2⁵, an anxious-avoidant/phobic personality is an anxious or timid person who struggles with safety vs. danger, feeling that they are in constant danger and must avoid it 🫣).

Regardless of all the controversy…Why did Avoidant Personality Disorder only show up in 1969?! Let’s check out what was happening in the world then. 🌎

The Zeitgeist of the Times of Avoidant Personality Disorder⁶

Personality is influenced at an individual level with genes, temperament, and early environments, but it’s also influenced by macrolevel layers such as culture and societal events. During the 1960s, there was a changing of world order and heightened polarization across the globe on the heels of World War II. In the United States (where Millon lived) in the 1960s, JFK was assassinated (1963); the Civil Rights Act was passed (1964); riots were rampant; MLK was assassinated (1968); Nixon, one of the most paranoid leaders in America, was elected president (1969)…and we have a push for people to submit to authority or else (😨phobic), rise up and challenge injustice (😡counterphobic), or avoid it all and become a hippie (✌️blissfully avoidant). Is it surprising then, that all of the sudden, we have a personality disorder characterized by fear and anxiety, who run from psychological pain? 🤷

Doc Fish’s Opinion on Avoidant Personality Disorder

I see SIGNIFICANT overlap among multiple theories! At the core, we have a personality that is fearful, anxious, and uncertain, and feeling inadequate because of it.

• The DSM calls this avoidant, focusing on the hypervigilance to rejection and low self esteem.
• Millon¹ calls this avoidant, focusing on the hyperalertness to danger and active movement away from others to avoid emotional pain.
• Psychoanalytic theory (in my personal opinion) calls it an anxious-avoidant/phobic personality⁵, focusing on avoiding danger and feelings of inadequacy and indecisiveness.
• The Enneagram⁷ describes a Type 6 who tends to be anxious and fearful of not having support, needing security and reassurance. They can be suspicious, self-doubting, defensive, and evasive, needing to test others’ attitudes toward them…Sounds a lot like Avoidant to me!

My conclusion is that schizoid and avoidant are separate personalities, but are not adequately captured in the DSM or by Millon¹. I actually favor the Enneagram⁷ to describe avoidant personalities with the Type 6, and think psychoanalytic theory’s phobic personality⁵ is also helpful to understand Avoidant Personality Disorder. Interestingly, Doc Bok has a different take on Avoidant Personality Disorder, viewing it as a trait. To learn more, check out Ep 46: Did the DSM Get it Wrong? A New Perspective on Avoidant PD.

Whatever your perspective on Avoidant Personality Disorder is, the symptoms of running from psychological pain, feeling anxious, struggling with low self-esteem, and avoiding others due to fear of criticism definitely exist - regardless of what you want to label it. If you desire to explore Avoidant Personality dynamics, therapy and/or psychological testing can help! If you’re in Virginia (or a PsyPact state), check out our private practice, Quest Psychological and Counseling Services for available services. If you’re a provider stuck on a case, we also offer consultations for mental health professionals!

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