Avoidant Personality Disorder

5 Interesting Facts of Avoidant Personality Disorder 

1. Avoidant personality disorder is a lifelong pattern of relating to people and the world that is characterized by social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation, and pronounced avoidance behavior
2. Avoidant personality traits are common and only constitute avoidant personality disorder when traits are inflexible, maladaptive, persistent, and cause significant functional impairment or distress
3. Diagnosed based on DSM-5 criteria; may coexist with other personality disorders, anxiety, or depression 
4. Psychotherapy is mainstay of treatment for this disorder; options include cognitive behavior therapy, psychodynamic treatment, and schema therapy 
5. Pharmacotherapy is not specifically recommended for avoidant personality disorder, but some medications used to treat social phobia (eg, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, pregabalin) may be effective, especially when social phobia is a comorbidity 

Pitfalls

• Comorbid psychopathology may confound diagnosis and make effective treatment challenging
• Failure to refer the patient to a psychotherapist who is experienced and familiar with treating personality disorders can result in inadequate treatment

• Avoidant personality disorder is a lifelong pattern of relating to people and the world that is characterized by social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation, and pronounced avoidance behavior 
  • Many patients display avoidant personality traits; disorder is present only when traits are inflexible, maladaptive, persistent, and cause significant functional impairment or distress

Clinical Presentation

History

• Patient may have a history of shyness, isolation, and fear of strangers and new situations beginning in infancy or childhood 
  • Patients become increasingly shy and avoidant during adolescence and early adulthood; unlike typical childhood shyness, which tends to gradually resolve
  • Symptoms tend to become stable and consistent over time and are not associated with developmental stage, sociocultural environment, medical condition, or substance use
    • However, symptoms do tend to become less evident with an adult’s increasing age
• Manifestations include: 
  • Avoidance of occupational activities that require significant interaction with others; declining promotions
  • Difficulty functioning in social or occupational settings
  • Difficulty making new friends
  • Avoiding group activities
• Others may describe the patient as shy, timid, lonely, and isolated 
• On assessment, patient may have evidence of:
  • Low self-esteem associated with self-appraisal as being socially inept or inferior
  • Excessive feelings of shame or inadequacy
  • Unrealistic standards for behavior resulting in reluctance to pursue goals, take personal risks, or engage in new activities involving interpersonal contact
  • Preoccupation with and sensitivity to criticism or rejection; distorted thinking that others’ perspectives are negative
  • Reluctance to get involved with people unless certain of being liked; restraint in intimate relationships owing to fear of being shamed or ridiculed
  • Reticence in social situations
  • Lack of initiation of social contact
  • Avoidance of social contacts and activity
  • Avoidance of close or romantic relationships
  • Lack of enjoyment from and energy for life experiences; reduced ability to feel pleasure or take interest in things
  • Intense feelings of anxiety, nervousness, tension, or panic often in social situations; fear of embarrassment
  • Worry about negative effects of past experiences and future negative possibilities
  • Feeling fearful or threatened by uncertainty

Physical examination

• Mental status examination findings are normal in the absence of comorbid conditions

Causes

• Cause is not fully understood but may involve environmental and genetic factors 
• Reported prevalence of 2.4% in the United States 

Risk factors and/or associations

Age

• Often begins in infancy and intensifies during adolescence and early adulthood 

Sex

• Equally prevalent in males and females 

Genetics

• The few family/twin studies available indicate that social phobia and avoidant personality disorder share a common genetic vulnerability factor 
  • Inherited factor is most likely a general predisposition, perhaps manifesting itself in a highly sensitive fear network within the amygdaloid-hippocampal area 
  • However, no neurobiologic research has been performed in avoidant personality disorder and there is no evidence that etiologic models for social anxiety disorder (including dysfunction of the amygdala, prefrontal cortex, hippocampus, and striatum) can be transferred to avoidant personality disorder 
  • It is not known whether allelic polymorphisms concerning the serotonin transporter and catechol O-methyltransferase that plays a prominent role in social phobia also have etiologic relevance for avoidant personality disorder 

Ethnicity/race

• What is viewed as inappropriate avoidance behavior varies across cultures; clinicians must be aware of such cultural differences 

Other risk factors/associations

• Physical and emotional neglect in childhood may be risk factors for avoidant personality disorder in adulthood 

Diagnostic Procedures

Primary diagnostic tools

• Diagnose on basis of patient history using a specific assessment instrument (eg, the Structured Clinical Interview for DSM-5 Personality Disorders, Personality Inventory for DSM-5, Clinicians’ Personality Trait Rating Form, Minnesota Multiphasic Personality Inventory-2) 
  • Must fulfill DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition) criteria: 
    • Pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by at least 4 of the following: 
      • Avoids occupational activities that involve significant interpersonal contact owing to fear of criticism, disapproval, or rejection
      • Is unwilling to get involved with people unless certain of being liked
      • Shows restraint within intimate relationships owing to fear of being shamed or ridiculed
      • Is preoccupied with being criticized or rejected in social situations
      • Is inhibited in new interpersonal situations owing to feelings of inadequacy
      • Views self as socially inept, personally unappealing, or inferior to others
      • Is typically reluctant to take personal risks or to engage in any new activities because they may prove embarrassing
• Exclude depression, anxiety disorders, and reactions to acute life stressors; unlike these, avoidant personality disorder is a persistent, lifelong pattern of maladaptation
• Exclude physiologic effects of medication/drugs or medical conditions (eg, head trauma) 
• Take into consideration patient’s developmental stage and sociocultural background 

Differential Diagnosis

Most common

• Social anxiety disorder
  • Disorder characterized by extreme fear of social situations; often coexists with avoidant personality disorder
  • Some have postulated that the disorders are not discrete conditions; rather, avoidant personality disorder is a more severe variant of social phobia 
  • Social anxiety is a key feature in both social anxiety disorder and avoidant personality disorder 
  • A sense of inferiority is identified in the criteria for avoidant personality disorder but not for social anxiety disorder 
  • Patients with avoidant personality disorder are emotionally guarded in contrast to people with social anxiety disorder 
  • Differentiate on basis of DSM-5 criteria 
• Dependent personality disorder
  • Patient is highly psychologically and emotionally dependent upon other people
  • Both avoidant personality disorder and dependent personality disorder involve feelings of inadequacy, hypersensitivity to criticism, and need for reassurance
  • Patients with avoidant personality disorder are preoccupied with avoiding humiliation and rejection; patients with dependent personality disorder want to be taken care of
  • Differentiate on basis of DSM-5 criteria
• Schizoid or schizotypal personality disorder
  • Patient exhibits extreme paranoia, unusual beliefs, tendency to isolate self, and apathy
  • Both avoidant and schizoid/schizotypal personality disorders involve social isolation
  • Patients with avoidant personality disorder are lonely and want relationships, whereas those with schizoid personality disorder may want to remain isolated
  • Differentiate on basis of DSM-5 criteria
• Paranoid personality disorder
  • Patient is consistently paranoid, mistrustful, and suspicious of others
  • Both avoidant and paranoid personality disorders involve social isolation and unwillingness to open up to others
  • Patients with avoidant personality disorder avoid opening up to others for fear of rejection; patients with paranoid personality disorder avoid opening up owing to fear that others have malicious intentions
  • Differentiate on basis of DSM-5 criteria
• Personality change due to another medical condition or substance use disorder 
  • Medical conditions, medication adverse effects, or substance use may cause patients to display avoidant behavior
    • Comorbid depression, anxiety, or substance use can exacerbate dysfunction in patients with personality disorders
  • Differentiated on basis of history of medical condition, medications, and drug use, which can cause personality change

Treatment Goals

• Improve patient’s social functioning

Admission criteria

• Patient is at risk of harming self or others

Recommendations for specialist referral

• Refer patient to a psychotherapist, and possibly a psychiatrist, for long-term treatment

Treatment Options

Individual therapy is mainstay of treatment

• Various therapeutic approaches:
  • Cognitive behavior therapy encourages patients to identify fears of rejection and criticism underlying the disorder and modify distorted thought processes
  • Psychodynamic therapy helps patients to understand influence of past on present behaviors, examine unresolved conflicts, and alter maladaptive behavior 
  • Schema therapy takes an integrated approach, incorporating cognitive behavior, psychodynamic, and gestalt therapy techniques
  • Behavioral therapies, such as social skills training and graduated exposure therapy; may be performed in group or individual setting
    • Promising results are seen in both group and individual settings; no evidence for superiority exists for either format
• Cognitive behavior and schema therapy currently have the strongest empiric evidence for efficacy 
  • No consistent trend in favor of longer or shorter treatment periods; treatment period studies range from 12 to 52 sessions

No specific pharmacotherapy for avoidant personality disorder

• However, treatments indicated for patients with social phobia may be applicable to patients with avoidant personality disorder owing to the high degree of overlap between the conditions 
• It is unclear whether pharmacotherapy offers benefits beyond those of cognitive behavior and other psychotherapy; a combination of medication plus psychotherapy is commonly used in practice 
• Medications used to treat social phobia include:
  • Selective serotonin reuptake inhibitors (eg, escitalopram, fluvoxamine, paroxetine, sertraline) 
  • Serotonin-norepinephrine reuptake inhibitors (eg, venlafaxine) 
  • Pregabalin
• Antianxiety medications and β-blockers may have a limited role in short-term relief of symptoms

Drug therapy

• Selective serotonin reuptake inhibitors (off-label)
  • Escitalopram
    • Escitalopram Oral tablet; Children and Adolescents 10 year and older: 5 mg PO once daily initially, then titrated to 10 to 20 mg/day PO to individual efficacy and tolerance, have demonstrated safety and effectiveness in clinical studies. Data are limited.
    • Escitalopram Oral tablet; Adults: 5 mg PO once daily initially, then titrated to 10 to 20 mg/day PO to individual efficacy and tolerance, have demonstrated safety and effectiveness in clinical studies.
  • Fluvoxamine
    • Fluvoxamine Maleate Oral tablet; Children and Adolescents 6 years and older: Initiate at a low dose (e.g., 25 mg/day PO at bedtime) to minimize side effects. Titrate by no more than 50 mg/week to effective dose. An average dose of 2.9 mg/kg/day +/- 1.3 PO was effective in one study. Max (12 years and older): 300 mg/day PO. Max (6 to 11 years): 250 mg/day PO.
    • Fluvoxamine Maleate Oral tablet; Adults: Initially, 50 mg PO at bedtime, then adjust as needed. Titrate in 50 mg increments every 4 to 7 days as needed until therapeutic benefit is reached. Mean effective dose per limited clinical trials is 200 mg/day, with a range of 50 mg/day to 300 mg/day PO. Total daily doses higher than 100 mg/day should be given in divided doses; if doses are unequal, give the larger dose at bedtime.
    • Fluvoxamine Maleate Oral capsule, extended-release; Adults: Initially, 100 mg PO at bedtime. Titrate as needed and tolerated in increments of 50 mg per week to a target range of 100 to 300 mg/day. During the titration phase, both the 100 mg and the 150 mg capsules may be needed to supply the daily dose; once stabilized, use the lowest effective total daily dose. Max: 300 mg/day. NOTE: Fluvoxamine CR was previously FDA-approved for social anxiety disorder in 2008, but the manufacturer petitioned for voluntary removal of the indication from the product label in 2011, and the FDA-approval for the indication was removed.50507
  • Paroxetine
    • Paroxetine Hydrochloride Oral suspension; Children and Adolescents 8 years and older†: 10 mg/day PO initially, then may titrate by 10 mg/day at intervals of at least 7 days based on response and tolerability. Max: 50 mg/day PO. Further study is needed to evaluate safety and efficacy for childhood anxiety disorders.
    • Paroxetine Hydrochloride Oral tablet; Adults: 20 mg/day PO is the initial and usual effective dose. May titrate by 10 mg/day at weekly intervals if needed and tolerated. Effective dose range: 20 to 60 mg/day; however, doses above 20 mg/day do not appear to provide additional benefit. DEBILITATED or GERIATRIC ADULTS: 10 mg PO once daily initially, may titrate by 10 mg/day at weekly intervals if needed; usual effective dose 20 mg/day. Max: 40 mg/day PO.
    • Paroxetine Hydrochloride Oral tablet, extended-release; Adults: 12.5 mg PO once daily initially, usually given in the morning. If needed, titrate at intervals of at least 1 week, in increments of 12.5 mg/day. Effective dose range: 12.5 to 37.5 mg PO once daily. Max: 37.5 mg/day PO.
  • Sertraline
    • Sertraline Hydrochloride Oral tablet; Children† and Adolescents† 7 years and older: 25 mg PO once daily, initially. After 1 week, increase the dose to 50 mg PO once daily. If necessary, increase at intervals of not less than 1 week. Max: 200 mg/day PO. Further study is needed to evaluate the long-term safety and efficacy of SSRIs in treating childhood anxiety disorders, including social anxiety.
    • Sertraline Hydrochloride Oral tablet; Adults: 25 mg PO once daily, initially. After 1 week, increase to 50 mg once daily. If necessary, increase by 50 mg/day at intervals of not less than 1 week. The therapeutic range is 50 to 200 mg/day. Max: 200 mg/day PO.
• Serotonin-norepinephrine reuptake inhibitors (off-label)
  • Venlafaxine
    • Venlafaxine Hydrochloride Oral tablet, extended-release; Adults: 75 mg PO once daily. There was no evidence in clinical trials that higher doses confer additional benefit. For some patients, it may be desirable to start at 37.5 mg PO once daily for 4 to 7 days to allow for tolerability before increasing to 75 mg PO once daily. Use lowest effective maintenance dosage and periodically reassess the need for continued treatment.
• Anticonvulsant (off-label)
  • Pregabalin
    • Pregabalin Oral capsule; Adults: 200 mg PO 3 times daily. Doses are usually titrated to the target dose over 1 week.

Nondrug and supportive care

• Cognitive behavior therapy
  • Collaboration between patient and therapist, with specific cognitive and behavior techniques, such as:
    • Socratic dialogue 
    • Monitoring of beliefs 
    • Analyzing advantages and disadvantages of avoidance 
    • Activity monitoring and scheduling 
    • Graded exposure assignments, also referred to as desensitization 
    • Behavioral rehearsal in role plays 
    • Self-image work including video feedback and social skills training 
• Psychodynamic treatment
  • Goal is for previously avoided effects (eg, sadness/grief, anger, tenderness) to be experienced and expressed adaptively by the patient
  • Therapist does the following:
    • Gently clarifies rather than confronts defenses
    • Empathizes with and exposes the underlying conflicted affect
    • Helps to regulate, rather than to provoke, anxiety
• Schema therapy
  • In treating avoidant personality disorder, the most relevant schema modes are:
    • Lonely child mode, which is characterized by feelings of loneliness, unworthiness, and being unloved
    • Avoidant protector mode, in which situational avoidance is activated
    • Detached protector mode, which is characterized by avoidance of inner needs, emotions, and emotional contact
    • Punitive parent mode, in which the feeling that oneself deserves punishment or blame is assumed to be activated

Comorbidities

• Comorbid depression is common and must also be treated 
• Other comorbid disorders, including other personality disorders, substance use disorders, or anxiety disorders, may be present and require their own treatment 
  • Approximately one-third of patients with avoidant personality disorder have comorbid social anxiety disorder 

Complications

• Patients with avoidant personality disorder may develop depression or substance use disorder owing to reduced quality of life and impaired social functioning

Prognosis

• Personality disorders are often assumed to be stable; however, improvement is common 
  • Avoidant behavior may remit or become less intense in adulthood 
    • Adults, in particular, may have reduced prevalence of traits over time 
  • Reported recovery rates after cognitive behavioral therapy range from 40% to 91%; however, recovery rates over 80% have been reported with schema therapy 
  • Some traits (eg, feelings of emptiness, social withdrawal) may decrease while desire for affection may increase 
  • Residual effects may be seen in the form of persistent functional impairment, continuing behavioral problems, and reduced future quality of life 

References

American Psychiatric Association: Avoidant personality disorder. In: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013:672-5