While clearly both disorders overlap psychodynamically, that is, they share many of the same dynamics as feelings of inadequacy and hypersensitivity to negative evaluation, I view the two disorders both as somewhat distinct psychodynamically and as significantly different structurally. For example, many individuals who are, dynamically speaking, shy and withdrawn do not complain of being afraid of speaking in public or of anything like that. Indeed, as many actors point out, as shy people, they actively come alive when on stage, undergoing a kind of temporary antiphobia—what the PDM calls a “converse manifestation: Counterphobic Personality Disorder,”7 only to revert to type when the “play” is over.
Millon and Davis also strongly suggest that AvPD and social phobia are two separate entities, for, as they note, social phobia is a symptom (Axis I), while AvPD is a personality problem (Axis 2). Thus, as Millon and Davis say, in AvPD, “there is a pervasiveness and diffuseness to the personality’s socially aversive behaviors, in contrast to the [social phobic’s] specificity of the phobic object and the intensity of the phobic response.”8 For characteristically avoidants express their anxiety in the form of what Reich calls “character armoring,”9 that is, in pervasive and diffuse interpersonal withdrawal behaviors that run the gamut of severity from modest problems with meeting, mingling with, moving close to, and remaining intimate and involved with other people to full shyness. Conversely, as Millon and Davis suggest, in social phobia, the “phobic symptom is not associated with the broad range of traits that characterize the [avoidant] personality, such as ‘low self-esteem’ [or] the ‘desire for acceptance.’ ”10 As Benjamin notes, social phobics do not possess the AVD’s sense of being “socially inept [and] personally unappealing, or inferior to others,”11 which lead the patient with AVD and not the social phobic to be “less likely to be married [and more likely to be] content (even relieved) to stay home by himself or herself.”12
In short, individuals with AvPD, unlike individuals with social phobia, are not primarily bothered, or bothered at all, by reactive situational anxiety attached to discrete “trivial prompts” such as signing a check in public or urinating in a public restroom—that is, they are not bothered by situations not particularly meaningful in themselves that they make significant by investing them with catastrophic implications. Rather, the life of the typical individual with AvPD is primarily consumed by diffuse, ongoing, dysfunctional relationships characterized by remoteness, shyness, and a tendency to recoil from closeness and intimacy. Patients with AvPD fear closeness, intimacy, and commitment itself, not a symbolic substitute, stand-in, or replacement for those things. In contrast, social phobics withdraw not from interpersonal relationships, but from interpersonal activities that are discrete trivial prompts that symbolize fears associated with interpersonal relationships—neatly packaged, tangible cues that act as stand-ins for interpersonal upheavals condensed and externalized to become outwardly expressed hieroglyphic representations of inner conflict. Because social phobics keep their personality as a whole out of their phobias, they generally remain outgoing and retain the ability to form close and lasting relationships. They might well be happily married and professionally successful. Their problems tend to consist “merely” of troublesome islets of panicky withdrawal—an insular expression of social anxiety that in turn spares the rest of their lives, island(s) of seemingly impersonal difficulty in the mainstream, with a mainland full of satisfactory personal relationships.
Examples of how social phobias refer to specific relational anxieties in a condensed form include a phobia of blushing signifying being criticized for turning red hot sexually; a phobia of speaking in public signifying being exposed as deficient and hence humiliated; a phobia of eating in public signifying being criticized for using the mouth in situations where observed (with homosexual issues implied); a phobia of urinating in a public men’s room signifying exposing one’s genitals to the man standing in the next urinal, in turn implying both homosexual vulnerability and fear of emasculation; and a phobia of signing one’s name to a check while others watch signifying a fear of yielding and hence of being submissive.
Some Case Examples
A patient expressed his generalized social anxiety indirectly and symbolically by pouring it into specific terror about urinating in public and signing his name to a check while others watched. He also condensed his fear of relating into a fear of driving to his partner’s home through green lights and over bridges. He was ultimately able to reach his partner, be romantic, and have sex, only during sex he would suffer from pangs of fear of commitment, which he expressed as a severe ejaculatio tarda (delayed ejaculation) that made it difficult for him to complete the sex act. Dynamically speaking, he was expressing deep interpersonal fears, but structurally speaking, he was expressing them in a condensed and displaced fashion, walling off and containing the fears in short-lived, discrete, pseudointerpersonal encounters that simultaneously referred to, obscured, and to an extent spared the real thing.
This state of affairs contrasts to that which existed with an avoidant, whose interpersonal life was globally tense and unfulfilling. People afraid of public speaking can take a job where they don’t have to do that, but this avoidant could not exist comfortably because he was unable to shake proffered hands, was so fearful of relating that he could not go outside without hiding to some extent, and not only developed an isolating telephonophobia, but also installed an answering machine not to receive, but to screen, messages, then neither answered the phone at all nor returned the messages that people left for him.
I believe that patients with AvPD have effectively made an unconscious choice to deal with their anxieties by developing mild to severe generalized relationship difficulties. In contrast, social phobics have made a different unconscious choice. They have chosen to remain interpersonally outgoing and related. They desire and hope to keep their whole personality out of things, and to do that, they limit their illness to part of their personality only—precisely so that they can remain generally outgoing, although with specific exceptions in the form of delimited deficits.
Importantly, social phobia differs from AvPD in its effect on others. Speaking figuratively, I divide psychological disorders into hot red pepper, garlic, and onion styles. Hot red pepper disorders trouble only the self, “upsetting the stomach,” while others escape distress. Garlic disorders trouble others through “bad breath,” but the self escapes “emotional dyspepsia.” Onion disorders trouble both others and the self as “interpersonal bad breath” accompanies “personal dyspepsia.” While social phobia is a hot red pepper disorder, mainly interfering with one’s own functioning, AvPD is an onion disorder, for it both affects the avoidants’ personal well-being and happiness and is troubling to and detrimental to others in the avoidants’ world.