Received: 9 January 2019 | Revised: 28 February 2020 | Accepted: 8 June 2020

DOI: 10.1002/jclp.23013

RESEARCH ARTICLE

Subjective experience of the origin and

development of avoidant personality disorder

Kristine D. Sørensen1 | Theresa Wilberg2,3 |

1 4
Eivind Berthelsen | Marit Råbu

1
Group Therapy Team, Aust‐Agder County
Outpatient Psychiatric Unit, Sorlandet
Hospital, Kristiansand, Norway
2
Department for Research and Development,
Clinic for Mental Health and Addiction, Oslo
University Hospital, Oslo, Norway
3
Institute of Clinical Medicine, Faculty of
Medicine, University of Oslo, Norway,
Norway
4
Department of Psychology, University of
Oslo, Oslo, Norway
Correspondence
Kristine D. Sørensen, Group Therapy Team,
DPS Østre Agder, Sorlandet Hospital HF,
Postboks 416, 4604 Kristiansand, Norway.
Email: kristine.sorensen@sshf.no
Funding information
EkstraStiftelsen Helse og Rehabilitering,
Grant/Award Number: 2016FO75667
Abstract
Objective: To better understand how persons diagnosed
with avoidant personality disorder (AVPD) make sense of
the origin and development of their current everyday
struggles.
Methods: Persons with AVPD (N = 15) were interviewed
twice using semi‐structured qualitative interviews, which
were analyzed through interpretative‐phenomenological
analysis. Persons with the first‐hand experience of AVPD
were included in the research.
Results: The superordinate theme, “a story of becoming
forlorn,” encompassed three main themes: “it goes all the
way back to when I was little,” “there was a distance be-
tween others and me,” and “transitions made it worse.”
Conclusions: Though the results are not necessarily spe-
cific to AVPD, the findings clarify how people with AVPD
can make sense of their current struggles by constructing
developmental life stories in the interplay between them-
selves as persons and the growing demands of their social
world. Furthermore, childhood relational vulnerabilities
may challenge the ongoing development of social cognition
and skills.

KEYWORDS
avoidant personality disorder, life stories, qualitative research,
service‐user involvement, subjective causes

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and
reproduction in any medium, provided the original work is properly cited.
© 2020 The Authors. Journal of Clinical Psychology published by Wiley Periodicals LLC.

2232 | wileyonlinelibrary.com/journal/jclp J. Clin. Psychol. 2020;76:2232–2248.

SØRENSEN ET AL | 2233

1 | INTRODUCTION

Avoidant personality disorder (AVPD) is associated with severe levels of functional impairment and subjective
distress (Wilberg, Karterud, Pedersen, & Urnes, 2009). Understanding the views and experiences of people who
seek therapy is important in improving mental health services (Larkings, Brown, & Scholz, 2017a). The process of
making sense of life experiences includes our understanding of how we came to be who we are, including the
perceived subjective origins and development of the psychological challenges from which we may suffer.
Current conceptualizations of AVPD by clinicians and personality disorder researchers describe persons di-
agnosed with AVPD as earnestly desiring interpersonal affiliation but simultaneously exhibiting social inhibition,
withdrawal, and isolation caused by feelings of inadequacy and fear of ridicule and rejection (American Psychiatric
Association, 2013; Millon, Millon, Meagher, Grossman, & Ramnath, 2012). Several environmental, temperamental,
and constitutional influences contribute to the development of psychological concerns related to the diagnosis of
AVPD (Lampe & Malhi, 2018), such as the association between AVPD and retrospective reports of adverse
childhood experiences. For example, Hageman, Francis, Fields, and Carr (2015) found an association between
AVPD, social–behavioral teasing, and sexual abuse. Reduced social involvement and engagement in childhood
(Rettew et al., 2003), attachment anxiety and abandonment in particular (Eikenæs, Pedersen, & Wilberg, 2015), and
deficient parental care (Joyce et al., 2003) have also been related to AVPD. Furthermore, a sensitive (Meyer &
Carver, 2000) or shy, anxious (Joyce et al., 2003) temperamental disposition and low scores on the normative
personality trait of extraversion (Kendler et al., 2019) are associated with AVPD. Torgersen (2009) emphasized
that though genes contribute to the development of personality disorders such as AVPD, they do so in a complex
interaction with situations and the environment. Biopsychosocial or diathesis‐stress models of biological vulner-
abilities in combination with environmental and social risks are considered relevant in describing the develop-
mental pathways of personality disorders (Paris, 1993, 2008).
Although the research paradigm of objectifying psychological phenomena has generated important knowledge
about mental disorders, some researchers suggest we are at a point of bewilderment over accumulated, detailed
empirical data and what they actually mean (Holzkamp, 1991; Lieberman, 1989; Parnas, Sass, & Zahavi, 2013).
Possibly, important features of mental life are beyond the reach of objectifying methods and we may need to
include the totality of human action to critically analyze prevailing concepts (Holzkamp, 1991; Lieberman, 1989;
Schraube, Osterkamp, & Holzkamp, 2013). Thus, it seems necessary to include a dialectic movement between
explanation and understanding to advance our knowledge (Sandage et al., 2008). We must consider how to view
human behavior in light of “the life historical, cultural context and meaning‐laden narratives that form, shape, and
define who we are” (Shean, 2016, pp. 14–15). To know more about mental disorders, subjective approaches must
be employed to better understand how experiences are presented or appear and how we make sense of them in an
embodied and situated relationship with the world (Galbusera & Fellin, 2014; Parnas et al., 2013; Smith, Larkin, &
Flowers, 2009).
Patients often think about what caused their mental disorders before and during their engagement with
mental health services (Larkings et al., 2017a; Williams & Healy, 2001). These causal beliefs relate to a person's
belief that various aspects such as biogenetic, psychological, or environmental influences caused or contributed to
the development of their mental disorder (Larkings et al., 2017a). How people understand the causes or origins of
their mental disorder may influence their coping responses and psychosocial functioning (Brown et al., 2007).
Weiner (1985) proposed analyzing causal attribution on three dimensions: Locus, stability, and controllability; that
is, whether the causes are considered to be located internally or externally to the person, perceived as controllable
or not by the person, and likely or not to change (Larkings, Brown, & Scholz, 2017b).
Attributional theory contends that biogenetic causes are usually internal and stable, often colored by an
essentialist view that genes may not be changed (Haslam & Kvaale, 2015; Larkings et al., 2017b). Biogenetic
explanations may reduce self‐blame and perceptions of personal responsibility and stigma. However, they may
also contribute to the public perception of people with mental disorders as dangerous and unpredictable, and
2234 | SØRENSEN ET AL

induce a lack of feelings of hope and control regarding recovery, both by and for patients (Haslam & Kvaale,
2015; Larkings et al., 2017b). In contrast to researchers' prominent focus on biogenetic explanations, patients
seem more likely to mention challenging life experiences and environmental aspects than biological or psy-
chological explanations as the cause of their mental disorders (Elliott, Maitoza, & Schwinger, 2012; Larkings
et al., 2017b). Seemingly, personal narratives of painful life experiences may be more compelling to patients as
they try to cope with and make sense of their problems (Elliott et al., 2012). Theories of attribution and beliefs
regarding illness are under‐researched, especially for personality disorders. However, the possible incongruence
of causal beliefs between mental health patients and their clinicians may negatively impact their therapeutic
relationship, and patients might find it difficult to address this difference. It is important for the collaborative
aspects of the therapeutic alliance to develop a shared understanding of explanatory models of mental disorders
(Elliott et al., 2012; Iselin & Addis, 2003; Larkings et al., 2017a).
Challenges surrounding self‐functions such as identity and maladaptive representations of self and others are
considered important aspects of personality disorders such as AVPD. These challenges include organizing sub-
jective experience in a narrative form (e.g., Dimaggio, Semerari, Carcione, Procacci, & Nicolò, 2006). Individuals'
perceptions of themselves as people become part of what constitutes their personality (Barresi, 1999). Auto-
biographical memories are central to how one constructs identity and understands and presents oneself
(Habermas, Bluck, & Eisenberg, 2000; Jørgensen et al., 2012; McAdams, 2006). Here, self‐identity is not just a
collection of traits an individual possesses or the result of environmental influences, but a process in which
individuals reflexively understand themselves in light of this biography (Giddens, 1991; McAdams &
McLean, 2013).
Previously, we reported findings from our qualitative research on the subjective lived experience of AVPD
as it relates to everyday life challenges and strategies (Sørensen, Råbu, Wilberg, & Berthelsen, 2019). The
findings highlighted an ongoing struggle with sense‐making, the sense of agency and identity, as participants
both feared and longed for connection with others and described searching for a sense of self (Sørensen et al.,
2019). Another topic addressed in the research project was how persons diagnosed with AVPD make sense of
the origin, causes, or development of current everyday concerns. As with other qualitative studies (e.g., Levitt
& Piazza‐Bonin, 2016, 2017; Råbu & McLeod, 2016), separate papers were published on the findings for
different research questions to present the rich, qualitative data in sufficient detail.
Thus, the aim of the present study was to further understand how participants diagnosed with AVPD make
sense of the origin and development of their current everyday struggles.

2 | METHODS

2.1 | Participants

2.1.1 | Interviewees

The interviewees were 15 patients with a primary diagnosis of AVPD undergoing therapy in outpatient clinics in
Norway. There were nine women and six men, and their ages ranged from 20 to 51 years (M = 33 years, standard
deviation [SD] = 9). Four patients had completed a primary level of education, nine a secondary level, and two a
higher education. No participants were working at the time of the interviews, and all were receiving welfare. Three
participants cohabited with a partner and children, three with a partner, two lived with their children, and seven on
their own. Eleven participants had undergone three or more courses of therapy, two had been through two to
three courses of therapy, and two were engaged in their first experience with therapy. Their therapies varied in
length, approach, and modality, and included individual therapy, specialized group therapies, and psychomotor
physiotherapy. During the in‐depth interviews, the eleven participants explained that in addition to their current
SØRENSEN ET AL | 2235

primary diagnosis of AVPD, they had also been diagnosed with various forms of anxiety and/or depression while in
therapy. Two participants had no recollection of former or cooccurring diagnoses, and two others reported only
having been informed of their AVPD. None of the participants mentioned receiving any other personality disorder
diagnosis. Considering former reports from research on cooccurring diagnoses of AVPD, our participants were
considered to represent common psychological concerns for people diagnosed with AVPD participating in therapy
in psychiatric outpatient clinics in a naturalistic way (e.g., Lampe & Malhi, 2018; Lenzenweger, Lane, Loranger, &
Kessler, 2007). Thirteen participants reported being informed about their diagnosis of AVPD during their current
course of therapy and two during their previous course. All participants reported seeking help to improve their
everyday functioning and reduce their level of suffering.

2.1.2 | Researchers

The group of researchers involved in this study included three clinicians, a Ph.D. candidate, and a specialist in
clinical psychology (A); a clinical psychologist and associate professor (B); a psychiatrist and professor (C); and
one theologian with a Ph.D. in Health Sciences (D), who mainly works as a hospital priest. Researchers A and C
work clinically with personality disorders. Together, the clinicians had backgrounds in schema therapy;
mentalization‐based therapy; relational, dynamic, and emotion‐focused therapy; and psychotherapy integra-
tion. All researchers share an interest in qualitative research on the subjective experience of various everyday
life phenomena; specifically, personality disorders, therapeutic processes, and outcomes. The first author (A)
conducted the interviews. Data analysis was mainly carried out by two of the researchers (A and B). B and D
facilitated reflection on our epistemological stance and analytical process, and C guided our discussion and
reflection on the analytical process within the context of the knowledge status of AVPD.

2.1.3 | Service user involvement

To increase the quality, relevance, and ecological validity of the study, we included persons with first‐hand
experience of AVPD in all phases of the research (Borg & Kristiansen, 2009; Veseth, Binder, Borg, & Davidson,
2013). The first author collaborated through all research stages with a coresearcher formerly diagnosed with
AVPD who had undergone several years of therapy. We established a reference group comprised of two
persons formerly diagnosed with AVPD with experience as patients and two experienced clinical psycholo-
gists. This reference group had numerous meetings to reflect on and give suggestions concerning the research
questions, interview guide, and findings that emerged during the research process.

2.2 | Procedures

2.2.1 | Recruitment

We sought experiences from people diagnosed with AVPD. Thus, we purposely recruited participants who had
received a primary diagnosis of AVPD by their therapists based on the Structured Clinical Interview for DSM‐IV Axis II
Personality Disorders (SCID‐II; First, Gibbon, Spitzer, Williams, & Benjamin, 1997).
We gave therapists at various outpatient hospital units verbal and written information about the research
project and brochures to distribute to patients who in their view, had a primary diagnosis of AVPD. Those who
expressed interest in participating were contacted by the first author by phone or text message and provided with
oral and written information about the research project. Ten persons agreed to participate and were interviewed.
2236 | SØRENSEN ET AL

In addition, nine participants from the research project, “An Examination of the DSM‐5 Level of Personality
Functioning Scale in a Representative Clinical Sample” (Buer Christensen et al., 2020; Buer Christensen et al.,
2019; Buer Christensen et al., 2018), who had agreed to be contacted at a later stage for additional research
purposes, were approached by the first author (A). They received written information about the research via their
therapists. Five of these persons agreed to participate and were interviewed.
There were no inclusion/exclusion criteria other than a primary diagnosis of AVPD, as we believed the
purposive selection procedure would ensure recruiting participants who wanted to participate in this study. No
incentive for participation was given. All participants gave their signed informed consent to participate. The project
was approved by the Regional Committees for Medical and Health Research Ethics. Biographical details have been
slightly changed to ensure anonymity and pseudonyms are used in the presentation of results.

2.2.2 | Interviews

To ensure that participants' views could be represented in a way faithful to their personal experiences, we used
open‐ended and lightly structured interviews. The interview guide was developed by the researchers, cor-
esearcher, and reference group to give direction to the first interview. A pilot interview was conducted to ensure
its suitability in addressing the research questions and to receive feedback on the participant's perception of the
interview situation. On the basis of the feedback, the interview guide was slightly revised. The questions related to
the research topic of how participants diagnosed with AVPD made sense of the origin and development of their
current concerns were as follows: “How do you think you became the way you are today?” “What do you think is
the origin/cause of your concerns?” When participants referred to theoretical concepts, the interviewer prompted
them to try to explain their views in everyday language or describe in their own words their understanding of the
concepts.
The first author then conducted two semi‐structured, in‐depth, face‐to‐face interviews lasting 60–90 min each.
Conducted approximately 2–3 weeks after the first, the second interview aimed to improve rapport and give
participants and the interviewer an opportunity to elaborate on topics introduced in the first meeting. A pre-
liminary analysis of the first interview formed the basis of the follow‐up questions in the second one. For nine
participants, the coresearcher read the anonymized transcripts and gave feedback to the first author regarding her
reflections and suggestions for further questions on important areas in the second interview. Participants re-
sponded by talking about aspects of their developmental experiences. We, thus, adapted the interviews to ac-
commodate these stories.
As the participants often conveyed being inexperienced with or challenged by the interpersonal nature of the
interviews as well as articulating and reflecting on their experience, the first author adapted her interviewing
technique to assist them in verbalizing their lived experience. The open‐ended questions seemed to initiate
insecurity about what to answer, and most participants needed clarifications and prompts to ease the dialogue. As
we began understanding the interview setting as an environment in which knowledge is constructed through a
relational interchange between two persons exchanging viewpoints, we allowed for more active dialogue in which
something was known and something became known in the relational context (Ezzy, 2010; Kvale, Brinkmann,
Anderssen, & Rygge, 2015).
Several participants informed the interviewer that frequent questions made it easier for them to talk; thus,
these adaptations consisted of a more active interviewing stance, prompting fuller descriptions through follow‐up
questions and supportive comments. Furthermore, the interviewer frequently checked whether she had grasped
the meaning of a participant's descriptions by sometimes repeating her understanding. Other aspects of the
interview setting were nonverbal attunement to becoming aware of when to linger or stop as participants searched
for ways to verbalize their experiences, and when to try various ways to phrase questions to elicit fuller de-
scriptions. Adapting to participants' discomfort in this way may deviate from the ideal of letting interviewees
SØRENSEN ET AL | 2237

elaborate without hindrance to elicit richly verbalized accounts to provide higher‐quality textual data (Kvale et al.,
2015). However, the interpersonal atmosphere of the interview and participants' ongoing feedback made us realize
that not adapting would likely result in reduced verbal responses and limited descriptions.
To accommodate participants' wishes for privacy and comfort, the interviews took place at the interviewee's
place of choice. Eleven people preferred to meet in an office at their hospital unit, and four wanted to be
interviewed at home. The interviews were audio‐recorded and transcribed verbatim, and all confidential in-
formation changed to ensure anonymity. All transcripts were verified once. The verbatim material was imported to
the software NVivo (QSR International, 2015) for principal analysis.

2.3 | Qualitative methods

We adapted a phenomenological hermeneutical epistemology approach using interpretative phenomenological

analysis (IPA; Smith et al., 2009). This approach does not view human beings as passive perceivers of an objective
reality but contends that “they come to interpret and understand their world by formulating their own biographical
stories into a form that makes sense to them” (Brocki & Wearden, 2006, p. 88). IPA assumes that individuals
interpret their experiences through self‐reflective processes to understand them (Brocki & Wearden, 2006). IPA is
ideographic because it studies a specific individual, situation, or event (Smith et al., 2009). It is phenomenological in
its concern with individuals' perceptions of objects or events and hermeneutic through its recognition of the
central role of the analyst in making sense of that personal experience (Smith, 2004, 2011; Smith et al., 2009). We
also emphasized the reflexive and exploratory aspects of hermeneutic phenomenology (Binder, Holgersen, &
Moltu, 2012; Finlay, 2008) through the research process.

2.3.1 | Data analysis

To move closer to the phenomenon and meaning‐making of participants' views of the origin and development of
their mental concerns related to their diagnosis of AVPD, we tried to become aware of and “bracket” our asso-
ciated lay understanding and theoretical assumptions of the causes thereof (e.g., van Manen, 2014). As such, we
assumed an inductive position allowing unexpected topics to emerge.
Each transcribed interview was read and reread to become familiar with the data. Then, each interview was
analyzed with a focus on preliminary comments and initial codes related to participants' meanings and experiences.
Furthermore, text segments were separated into broad content units that represented various aspects of parti-
cipants' subjective views on the origin and development of their current psychological concerns. The first author
continued the analysis by further coding the meaning segments in each case before highlighting similarities and
differences across cases. Segments that seemed to consist of more superficial descriptions became enriched when
considered in light of those drawn from the interviews with more articulate participants (Kirkevold &
Bergland, 2007).
Themes took form through moving between the rereading of transcripts, writing of drafts, and reflective dia-
logue between the authors. One example of how the themes took form was how our attention was first drawn
toward the adverse childhood events initially coded. Later, dialogue between the authors and rereading the tran-
scripts made us consider that the common element of participants' accounts was instead of how they all looked back
at their childhoods and youth for the origin and development of their current struggles. Thus, the emphasis changed
from what we later understood as our fore‐understanding or tendency to look for causality, and subsequently, our
attention shifted toward the salience of life stories in meaning‐making.
Together, the themes took shape as an overarching life‐story of subjective experiences in which variance and
nuances build on each other to represent various subjective views on important influences on participants' current
2238 | SØRENSEN ET AL

struggles. These themes depict the structure of the meaning and experiential accounts of participants' descriptions
of the origin and development of their current struggles related to the diagnosis of AVPD.

2.3.2 | Credibility checks

The researchers applied various credibility checks. We gave participants the opportunity to correct or add in-
formation in the second interview through the question: “Is there anything important I did not ask about?”
Cooperation with the coresearcher and reference group helped reduce researcher bias and kept the service user
perspective salient in the analysis. For example, during our reflections, service users directed our attention to the
importance of how they, and some participants, considered their relationships with their parents as good and
normal, questioning our initial tendency to focus on possible poor relations with their significant others. This
resulted in continuously ensuring that the findings clearly reflected more nuanced descriptions of the subjective
experiences of participants who conveyed good or normal relationships with their parents.
All researchers continuously reviewed the analysis to keep multiple viewpoints active in understanding the
complexity of the data. Finally, we contacted the participants and asked for feedback on a draft of the article and a
summary of the findings. Ten participants responded to our request. They all reported recognizing themselves in
the main themes and corresponding general descriptions. All commented on how some developmental experiences
fit their own experiences, whereas others did not, reasoning that they were different people with different life
stories and that this was well depicted in the findings. Some said it felt good to read about how they were not the
only one with these experiences.

2.3.3 | Reflexivity

In an IPA, the aim is to stay close to participants' descriptions and give voice to the sense‐making of their
experiences. Simultaneously, one recognizes that one's own meaning‐making unavoidably colors one's inter-
pretations (Smith et al., 2009). To make this dialectic tension transparent, one acknowledges one's presumptions
and stays aware of the interview context (Binder et al., 2012; Finlay, 2003). Therefore, we held repeated meetings
to reflect on our theoretical stances. The first author kept a research diary to record reflections directly after the
interviews when transcribing and reviewing the audio recordings and throughout the analysis. These notes on the
interpersonal context and possible meaning were used in reflections with the other researchers and aimed
to capture an embodied experience to articulate inchoate meanings of the interpreted text while staying close to
participants' verbalized experiences (Rennie, 2012). Furthermore, we strived to keep the reflections open to
various perspectives during reference group meetings and balance the ongoing questioning of personal resonance
with emerging themes while staying close to the empirical data. Researcher A wrote notes during the meetings
with the reference group to ensure all perspectives and reflections were considered during further analysis of the
transcripts. The service users and coresearcher contributed to a growing focus on what seemed missing in par-
ticipants' life stories, namely, the lack of closeness, connection, protection and guidance, and feeling recognized as
a subject while growing up.

3 | RESULTS

Our analysis supported an overarching superordinate theme: “A story of becoming forlorn.” This superordinate
theme represents the most abstract level of analysis and reflects the importance participants placed on their
developmental history and corresponding experiences when trying to understand the origin and development of
SØRENSEN ET AL | 2239

their concerns. It encompassed three main themes: “it goes all the way back to when I was little,” “there was a
distance between me and others,” and “transitions made it worse.” The three main themes are mutually related and
interconnected, describe variances and nuances in participants' descriptions, and together form an experiential
account of their life stories of a growing emotional and relational distance that worsened as they moved through
transitional periods in their lives.
The representativeness of our findings and recurrence of themes across individual cases is indicated by the
frequency labels general, typical, and variant, as suggested by Hill et al. (2005). The main themes were general as
they applied to all or all but one case and are referred to in the text as all participants. The themes considered
typical applied to more than half the cases and were referred to as most participants. Variance within themes was
represented by less than half but more than two cases. This is reported as some participants in the text.
Themes are illustrated below using quotes from individual participants.

3.1 | A story of becoming forlorn

In participants' descriptions of their subjective views on the origin and development of the mental struggles, they
associated with their diagnosis of AVPD emerged a story of a growing child, youth, and young adult that seemed to
become increasingly alone, lost, unhappy, and bereft of comfort. This experience lingered in their stories, even in
descriptions of more positive events or relationships. The developmental descriptions of becoming forlorn were often
directly stated, but most noted not being aware of their own growing sense of estrangement. Their descriptions
seemed colored by the degree to which their own developmental stories made sense to them, or whether they had
experienced their upbringing as normal. “Normal” here means that some participants conveyed being unaware that
something was amiss, had not considered there were other ways for families to function, or being content with their
relationships with their family of origin. Thus, they could not grasp why they felt increasingly forlorn.

3.1.1 | It goes all the way back to when I was little

All participants in some way considered their current concerns as rooted in their developmental history.
Although the degree to which they were satisfied with their answers regarding why they currently struggled
varied, all participants had considered how various issues and events contributed to the development of their
current personality and functioning.
Some participants specifically referred to hereditary influences and mentioned mental illness, genetics, or
shyness in the family. These participants also spoke about how various life events had contributed to the devel-
opment of their concerns. Thus, no participants described hereditary aspects as the sole cause of their psycho-
logical problems. They told various forms of stories from their upbringing about their relationships with their
families of origin and/or their peer relations, as well as experiences at school and in leisure activities.
Two main developmental issues emerged from the descriptions of the origin of participants' mental struggles.
The first was having troubled parents and the second was having been bullied and/or rejected by peers. Some
described a combination of having troubled parents and experiencing years of bullying and rejection, and others
attributed one or the other as the main cause of the development of their current concerns.
Participants who perceived their home environment as the main contributor to the development of their
current concerns did not mention rejection or bullying beyond what they considered normal teasing. Parti-
cipants described parents they perceived as having struggled with substance abuse (alcohol and prescription
medication); being aggressive, mean, or violent; struggling with mental illness (depression and anxiety), or
having severe physical illness. Some parents struggled to keep the family together, had burdensome work and
were stressed, or did not understand the participants as children.
2240 | SØRENSEN ET AL

I had a father with a dangerous temperament. He had very intense outbursts of anger and said many ugly
words. Furniture was thrown onto the walls. His eyes would light up, and his mouth would froth. It was very
unpredictable. You never knew when and why.
(Lilly)

Those who perceived bullying and rejection as the main cause of their current concerns were clear on
considering their parents as having provided a good or ordinary upbringing. The bullying was described as verbal or
physical, or as rejection and being left out of the fellowship of their peers. The degree of bullying and/or rejection
varied from episodic to continuous over many years. “I was one of those they threw snowballs at. They smothered
me in snow and all that. They took my backpack and called me ugly things in the hallways” (Anita).
Participants who perceived both troubled parents and bullying/rejection by peers as the origins of their
current concerns conveyed a sense of having to succumb to their situation. “It did not help much to be beaten at
home and then go to school and get bullied there too” (Ronny).
Succumbing seemed related to a sense of having to endure the abuse.

3.1.2 | There was a distance between others and me

This theme concerned the subjective experience associated with the description of the participants of the develop-
mental event perceived as contributing to their current concerns. All participants conveyed a sense of having been a
child, youth, and young adult who experienced relational and emotional distance from their core families and/or peers.
Those who identified their home environment and troubled parents as important causes of their current concerns
noted that they were not given the love, care, and protection they needed during their childhood years. They felt like
their parents disregarded them when they expressed anxious or depressed feelings and thoughts or when calling
attention to their needs as if their parents were not attuned to them as children. One participant expressed that his
family was so different from him in their general view of life that they would never be able to understand or empathize
with him. Thus, there was no one to turn to or to give guidance or care for him. There was little warmth, and no hands
to hold on to. Some experienced feeling like “an orphan,” as if nobody loved them for who they were. “There was no one
there to take care of me, to talk to, to ask about things, or to help me become confident in anything” (Elsa).
Participants who identified bullying and rejection by peers as the main cause of their current concerns
conveyed a sense of feeling shunned and estranged. Although most had a few friends, they felt left out, as if there
was no room for them and they were not important. For them, this perceived rejection was apparent through
physical and verbal bullying, and through more covert episodes of not being invited to join activities or being told
they were unwanted. “They had their fun bullying me. In addition, the girls…you know, there was room for
everyone, and then there was no room for me. I was not invited” (Janne).
All participants concluded that no one would listen to them, it would be of no use to tell anyone how they fared
or ask for help to resolve issues at home or related to their peers. Some said they had been frightened into
following strict rules of conduct in the face of unpredictable and perhaps aggressive reactions by one parent and
simultaneous lack of protection from the other. Some thought they should not burden others with their own
concerns, as they did not wish to bother their parents but rather support them.
Those who said their family was “normal” seemed to not have considered talking to their parents about
their concerns while growing up. They did not seem to perceive this family norm of not talking as problematic
or amiss at the time. “My father died when I was ten. We never talked about it. I remember the priest asking
me how I was and I just told him that I was okay. That was it” (Tom).
Some participants had someone to turn to for a sense of warmth and comfort: a grandparent, an aunt, or an
older sibling. This, someone, provided moments of safety and nurturance in which they found relief from loneliness
SØRENSEN ET AL | 2241

or fear. However, the participants eventually had to return to their homes and everyday lives, meaning relief was
temporary.
As the participants became young adults, the distance evolved into a more obvious withdrawal and loneliness,
as the interpersonal or social settings surrounding them continued and evolved without them.

3.1.3 | Transitions made it worse

This theme captured how all participants found that various developmental passages or contextual changes
made matters worse for them. These passages or changes seemed characterized by an atmosphere of gra-
dually becoming increasingly forlorn. The challenges faced as a small child, such as being shy and disliking
attention, were carried forward into new situations with growing expectations of being able to socialize and
present oneself, such as introducing oneself to a new group of people in a new class or at a leisure activity.
These demands to understand and adapt to new rules of interaction, new practical tasks, and new issues to
solve became impossible to manage, adapt to, or understand. It seemed as though the participants could not
reorient themselves to the new challenges a new situation or context demanded of them, accentuating their
difficulties. They left the perceived safety of something difficult but well known to face the daunting
unknown.

The worst thing I ever experienced was finishing secondary school and starting high school. It started
becoming a bit safe at secondary school. I knew who most people were and where to go. There were some
safe places. Then, I was supposed to go somewhere new with completely new people. I could not handle it.
I just cried and cried. It was so scary. I lost all control.
(Amanda)

In contrast to most participants, two described how a change in the school environment gave them the
opportunity to start afresh and move away from others' perceptions of them as shy or stupid. They began to feel
included in their new setting and described their enjoyment and mastery at school. However, this period of
reestablishment was temporary, and the newfound positive experiences were lost in the next transitional period.
Some underscored how becoming a teenager changed social interaction demands from playing to talking
together. This included hanging out socially and facing the beginning of romantic involvements. They ex-
plained how they failed to participate as others did. A sense of being different, not knowing what to say, or
not understanding social rules seemed to grow within them, making them feel more insecure and awkward.
“When I was 15, someone told me I was closed‐off…I did not know that I should have said something personal.
I thought, what is it that people share or expect you to share?” (Eva)
Entering the phase of early adulthood, most participants had romantic relations and some settled with a
partner. The descriptions of these early romantic relationships were understood as something one was expected to
do, but that lacked emotional intimacy.

It was just… he wanted to be with me and I was like, oh well, okay. There were never any feelings involved
really on my part. What to say? You kind of always do it because it is practical and it is bad to be on your
own. So if someone liked me, that was enough in a way. But I never felt my own feelings.
(Elsa)

Participants described the period of becoming a young adult and relating to or entering work settings as very
challenging. Some never started working at all. They did not apply for work, as the thought of interviews was too
2242 | SØRENSEN ET AL

frightening. They thought they could not manage or did not consider it possible because of the level of their
psychological suffering.

When I finished school, I found it very hard to write a job application. I thought, I have my degree, but
nobody will hire me and I cannot make it through an interview. I did get an internship and I did my job well,
but the social part did not go well. I got an offer to work there, and the job was good. But I said no to it
because I felt like I made a fool out of myself.
(Anna)

Most participants became employed but could not live up to what they perceived was expected from
them, could not communicate their concerns or receive guidance, and became overwhelmed by feelings of
insecurity and anxiety or exhausted by trying to cope. These participants resorted to taking sick leave and
later received various forms of welfare.
An essential part of their struggle with transitions was having to repeatedly endure situations on their own.
“Every day of every year was like a battle. I prepared and just had to try my best. It was exhausting” (Anita). It
seemed they did not consider the possibility of asking for help or guidance, as no support would be available to
them. They were not able to overcome the distance between themselves and others on their own and it seemed
they had little available resources to draw on when facing the unfamiliar as if they lacked a stable internal base
to venture out from into the unknown. Thus, they came across as being left with a fragile point of departure to
reevaluate and restructure themselves and their context in the face of new information.

4 | DI SCUSSION

The aim of this study was to better understand how persons diagnosed with AVPD made sense of the origin and
development of their current everyday struggles. When interviewed, the participants responded with a developmental
focus in which a combination of hereditary aspects such as temperament or mental illness in the family was viewed as
being in a dynamic interplay with challenging life story events concerning their relationships with their family of origin
and peers. These aspects took the form of life stories with an experiential atmosphere of feeling increasingly forlorn as
a distance evolved between themselves and others, which worsened during transitional periods.
Next, we relate our findings on participants' views on the origin and development of their psychological
challenges to theory, thus enhancing understanding of AVPD within this context.
Our participants emphasized a developmental perspective of the causes of their current struggles in which a
narrative facilitates meaning‐making. Our findings align with the suggestion of Elliott et al. (2012), who found that
using personal narratives to relate painful life experiences and mental concerns is compelling. Furthermore, our
findings indicate that biogenetic explanations may be included as one aspect of a life story on how one becomes the
person one is. McAdams (2006) views personality as compromising dispositional traits, characteristic adaptations,
and integrative life stories. Dispositional traits are broad and decontextualized constructs such as the traits described
in the Big Five model that describe what people are generally like. Characteristic adaptations are aspects of per-
sonality contextualized in time, place, or social role, and thus include motives, goals, attitudes, and coping skills.
However, integrative life stories explore how a person makes sense of their life through the construction of nar-
ratives of the interplay between the person and their social world. Although often multiple and from various—
sometimes conflicting—viewpoints, all small and large stories become woven together and continuously develop and
shape the lived experience (McAdams, 2006). Indeed, our participants answered questions about the causes or
origins of their current challenges by telling stories about their upbringing. Various forms of attributing causes were
woven into these life stories, such as how some participants considered internal hereditary aspects of their per-
sonality as more or less challenging depending on their external environment. Findings from studies on subjective
SØRENSEN ET AL | 2243

experiences play an important role in this model, which emphasizes the way a person makes sense of their own
biology, environment, and events throughout their life course. People build their narrative identity as well as
representations of others and the world, which influences their sense‐making of what they do and what happens to
them in a dynamic interplay (Dimaggio et al., 2006).
As a child develops, traits, characteristic adaptations, and life stories evolve in continuous interplay. In a
developmental pathway perspective of normal and abnormal development, biology interacts with the psychosocial
environment to give way to both the risks and resilience of a person's characteristic patterns of thinking, feeling, and
behaving (Cicchetti & Toth, 2009; Tackett, Herzhoff, Balsis, & Cooper, 2016). A vulnerability‐stress model of
personality disorder etiology (Paris, 1993, 2008; Perris, 1999) may improve understanding of the risks in the
developmental pathway perspective.
Certain aspects of child and youth development were especially important in participants' descriptions in this study:
Emotional and verbal modes of communication in their families of origin likely contributed to the experience of distance
in their relationships with their significant others. It seemed this sense of distance transferred to other social contexts
through a gradual shift toward the importance of peer relations. Difficulties in these areas evolved through transitional
phases in their development. Our findings regarding the subjective view of the origin of current struggles could indicate
the importance of early insecure attachment models through participants' stories of their relationships with their
primary caregivers. These insecure attachment models may constitute the interpersonal vulnerabilities participants
carried with them throughout their development. Attachment theory provides a promising theoretical and empirical
framework for understanding personality disorders, although the relationship between various personality disorders and
specific insecure attachment patterns remains unclear (Chiesa, Cirasola, Williams, Nassisi, & Fonagy, 2017; Tackett et al.,
2016; Wilberg, Eikenæs, Skulberg, Urnes, & Pedersen, 2018). However, Eikenæs, Pedersen, and Wilberg (2016) found
that fear of abandonment could play an important role for people diagnosed with AVPD. Our findings imply that rather
than fearing abandonment, our participants already felt abandoned and alone with themselves.
The participants in this study who reported growing up with troubled parents described an emotional and relational
distance and felt there was no one to care for or guide them. Some likened themselves to orphans. Thus, both proximity
seeking and support for autonomy were likely experienced by most as limited, contributing to their assumed insecure
attachment patterns. While not all participants described their relationships with their parents as troublesome, some
aspects of their early relational experiences still challenged their interpersonal functioning later in life. Stern (1985)
differentiated between attending to a child's physiological and physical needs and attuned intersubjective relatedness,
impact of nonattunement, ongoing misattunement, and the selective use of attunement, which contribute to shaping the
experience of expressions, preferences, and internal states. The participants who described their relationships with their
parents as good might not have considered these relations as wanting or insecure, but may still have had selective and/or
misattunement experiences that influenced their procedural memory systems to give way to intersubjective vulnerability.
At the core of attachment bond is the basis of emotional communication, namely, a caregiver's attunement to a
child's internal states of bodily arousal, which need to be appraised and regulated in this dyadic relationship
(Schore & Schore, 2008; Stern, 1985). This dyadic attunement process of regulation contributes to the child's self‐
regulation capacity, and the corresponding experiences become part of their implicit procedural memory systems
(Beebe & Lachmann, 1998; Schore & Schore, 2008; Stern, 1985). These procedural forms of representations
underlie many forms of skilled actions such as social skills and intimacy and seem to develop both in parallel and in
interaction with symbolic memory systems (Lyons‐Ruth, 1999). Participants who perceived good relationships with
their parents may not have perceived this possible tacit vulnerability as a deficit because of its procedural nature,
but rather as being normal within their family context.
As we move from childhood into adolescence, the importance of peer relationships increases. Peer relations
become important for socialization for normative development because peers provide the context for critical age‐
appropriate competencies such as building and maintaining friendships and maneuvering one's position within the
social ranking system (Rudolph, Lansford, & Rodkin, 2016). Furthermore, the peer group may be a reference point for
building one's social (Tarrant, MacKenzie, & Hewitt, 2006) and narrative identity (McLean & Jennings, 2012). Most
2244 | SØRENSEN ET AL

participants in our study described experiences of victimization and rejection by their peers, which likely contributed
to reinforcing their experienced distance from others. Some theories propose that social withdrawal may be a
consequence of and contributor to peer rejection (French, 1988, 1990; Wood, Cowan, & Baker, 2002). Repeated
relational and overt victimization has been found to have insidious debilitating effects such as increased psycholo-
gical distress in the form of internalizing problems (e.g., depression and low self‐esteem), self‐blaming attributions,
and interpersonal maladjustment, which could all be part of a vicious cycle spurring further victimization (Dill,
Vernberg, Fonagy, Twemlow, & Gamm, 2004). Rejection and exclusion from a group might increase insecurity and
activate attachment‐related strategies that mirror the internal working models of close relations (Rom & Mikulincer,
2003). The growing gap between the social knowledge and competencies of the participants and their peers may also
have accentuated the experience of being different and thus of falling short in social ranking.
Overall, the findings imply fewer experiences talking about inner mental states with participants' primary
caretakers and peers. Children's participation in conversations that reference mental states in various contexts
supports the developing comprehension of unobservable mental states, thus contributing to the developing theory
of mind (Fernández, 2013; Guajardo & Watson, 2002). Furthermore, these early conversations with caretakers are
a form of practicing how to articulate one's own feelings and thoughts about events and receiving feedback that
validates, challenges, or develops these meanings (Guajardo & Watson, 2002). This mutual dynamic reflection on
past events is believed to contribute to later narrative identity development (Guajardo & Watson, 2002), which
develops into personal reasoning about their own life span during adolescence. Their own coherent biographical
life story can contribute to self‐continuity and self‐understanding (Habermas et al., 2000; McAdams & McLean,
2013). The participants expressed either having missed these conversations on mental state, longing for them, or
being unaware of how experiences of reflection though conversation shape the sense of self and others.
Together, the presented findings and relevant theories highlight the importance of personal narratives for meaning‐
making regarding the subjective experiences of the origin and development of struggles related to the diagnosis of
AVPD. These life story narratives are considered central to the construction of identity and self‐understanding, and self‐
presentation (Habermas et al., 2000; Jørgensen et al., 2012; McAdams, 2006). Our participants' narratives start from
early childhood, during which events and the formation of interpersonal patterns are important, as are the later peer
relations of adolescence. Thus, interpersonal relations throughout their development were emphasized as important in
the development of their sense of self and being‐with‐others (Stern, 1985; Sullivan, 1953). Furthermore, investigating
how various developmental experiences come to make sense to the person may clarify how similar adverse childhood
events lead to various outcomes and vice versa (e.g., Tackett et al., 2016).
Our findings give voice to participants' understanding of how the interplay between hereditary issues and chal-
lenging life events may create an experience of emotional and relational distance and a sense of being left on one's own
that contributes to difficulties with social cognition and skills that become amplified during transitional periods.
Psychotherapy may provide an opportunity to better develop this autobiographical narrative identity. When
people tell stories about their lives, they interpret and attribute meaning to various life events that may influence their
sense of self and self‐organizing experiences (Angus & McLeod, 2004; Polkinghorne, 2004). Furthermore, interpreta-
tions and attributions are created in social interaction, and this coconstruction of meaning may contain specific
memories of cognitive, emotional, and somatic aspects of both explicit and implicit subjective experiences (Dimaggio,
Montano, Popolo, & Salvatore, 2015; Richert, 2003). Thus, as one develops an autobiographical story in therapy, the
interpretation and attribution of an event may become the focus, not just the retelling of events themselves
(Polkinghorne, 2004). Therapists may explore these aspects of patients' personal narratives to organize meanings and
better understand the patient while staying aware of how the interpersonal context of the therapeutic relationship,
own narratives of understanding psychological concerns, and therapy may influence the coconstruction of these stories
(Richert, 2003). Such reflexive therapeutic conversations may improve the therapeutic alliance and reconstruct per-
sonal narratives in a way that facilitates the wished‐for change (Angus & McLeod, 2004).
Thus, patients diagnosed with AVPD may benefit from a common focus on sense‐making through collaboration
on a shared exploration of experienced origins and development of AVPD. Increased awareness of early and later
SØRENSEN ET AL | 2245

procedural aspects of interpersonal patterns and social skills development may lend a nonjudgmental view to their
attributional thinking regarding their autobiographical selves and current struggles.

4.1 | Limitations

The participants' accounts are subjective and retrospective and, thus, imply neither objectivity nor generalizability in
terms of etiology or the factuality of events. No formal assessment procedures were part of this study. All participants
were recruited from a hospital setting, and their learning of various theories of etiology may, thus, influence the
findings. Our findings and the corresponding conveyed narratives were part of the cultural context in which they
belong. The participants were Norwegian and participated in the sense‐making of psychological challenges assumed to
be communicated by therapists who apply various therapeutic approaches in a hospital setting. These contextual
aspects are considered important because of the cultural relativism of our sense of self and social roles (Mulder, 2012).
The scope of the findings is limited by the aim of this study, which was an inductive and ideographic inquiry into the
subjective experience of the origin and development of AVPD. Thus, the analysis did not aim to compare participants'
subjective experiences based on their various characteristics, the influence of cooccurring diagnoses, or treatment
experiences. Furthermore, the findings do not distinguish the origins and development of personality disorders or
between normality and pathology. However, these important topics could be the subject of future research.

5 | C O N CL U S I O N

Though we cannot say that the results are specific to AVPD, the findings for the subjective experience of the origin
and development of AVPD provide insight into how persons with a primary diagnosis of AVPD may make sense of
their current concerns by constructing life stories about the interplay between themselves as persons and their
social worlds. Our findings can also be viewed through the lens of the developmental psychopathology framework,
in which participants' relational vulnerabilities give rise to cumulative effects that spill over to challenge several
domains of social cognition and skills. Thus, these findings may inspire therapists to frame an etiological under-
standing and coordinate their own views with patients diagnosed with AVPD.

A C K N O W L E D GM E N T S
We are very grateful to the participants who were willing to share their experiences, as well as to the service users
who provided invaluable contributions to this study. This project has received financial support from the Norwe-
gian ExtraFoundation for Health and Rehabilitationthrough the Norwegian Council for Mental Health and
Sorlandet Hospital, Norway. Scientific editing by Stephanie Felgoise.

C O NF L IC T O F IN T E R ES T S
The authors declare that there are no conflict of interests.

ORCID
Kristine D. Sørensen http://orcid.org/0000-0001-9848-0521

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How to cite this article: Sørensen KD, Wilberg T, Berthelsen E, Råbu M. Subjective experience of the origin
and development of avoidant personality disorder. J. Clin. Psychol. 2020;76:2232–2248.
https://doi.org/10.1002/jclp.23013
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