Avoidant Personality Disorder

Primer

Avoidant Personality Disorder is a personality disorder where individuals are timid and shy, and because they are so uncomfortable and afraid of rejection or criticism, they avoid social contact. However, they do wish to have friends, unlike individuals with schizoid personality. In addition, they are self-critical and have low self-esteem. If affected individuals are given strong guarantees of uncritical acceptance, however, they will make friends and participate in social gatherings.

Epidemiology
  • The estimated prevalence is 2.4%.[1][2]
  • Males and females are equally diagnosed.[3]
Prognosis
  • Individuals can have major problems in social and occupational functioning due to fears of being criticized or rejected.
  • In contrast to normal shyness, individuals with avoidant personality disorder may become increasingly shy and avoidant during adolescence and early adulthood.
    • However, symptoms do tend to become less evident and/or will remit with age.
Comorbidity

DSM-5 Diagnostic Criteria

A 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 4 (or more) of the following:

  1. Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection.
  2. Is unwilling to get involved with people unless certain of being liked
  3. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed
  4. Is preoccupied with being criticized or rejected in social situations.
  5. Is inhibited in new interpersonal situations because of feelings of inadequacy.
  6. Views self as socially inept, personally unappealing, or inferior to others.
  7. Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing

Psychopathology

Differential Diagnosis

  • Social anxiety disorder
  • Agoraphobia
    • Avoidance behaviours characterizes both avoidant personality disorder and agoraphobia, and they often co-occur.
  • Dependent personality disorder
    • Both avoidant personality disorder and dependent personality disorder are characterized by feelings of inadequacy, hypersensitivity to criticism, and a need for reassurance. Although the primary concern in avoidant personality disorder is avoidance of humiliation and rejection, in dependent personality disorder the focus is on being taken care of, and there is intense abandonment fear. However, it is important to note avoidant personality disorder and dependent personality disorder commonly co-occur.
  • Schizoid and schizotypal
    • Similar to avoidant personality disorder, schizoid and schizotypal personality disorder are characterized by social isolation. However, in avoidant personality disorder individuals want to have relationships with others and feel their loneliness deeply. Contrast this with schizoid or schizotypal personality disorder, where they may be content with and even prefer their social isolation.
  • Paranoid personality disorder
    • Paranoid personality disorder and avoidant personality disorder are both characterized by a reluctance to confide in others. However, in avoidant personality disorder, this reluctance is due to the fear of being embarrassed or being found inadequate, rather than a fear of malicious intent by others.
  • Personality change due to another medical condition
    • Avoidant personality disorder must be distinguished from personality change due to another medical condition, in which the traits that emerge are attributable to the effects of another medical condition on the central nervous system.
  • Substance use disorders
    • Avoidant personality disorder must also be distinguished from symptoms that may develop in association with persistent substance use.

Treatment

Psychotherapy is the main treatment of choice, and group modalities may be even more helpful. Cognitive behaviour therapy (similar approach for social phobia), psychodynamic therapy, and schema therapy have all be studied.[5] Therapists should encourage gradual exposures into the world, and stay aware of threats to the patient's self-esteem.

Recommended Reading

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Guidelines

Personality Disorder Guidelines

Guideline Location Year PDF Website
World Federation of Societies of Biological Psychiatry (WFSBP) International 2009 - Link

Resources

For Patients
For Providers
Articles
Research

References

1) Lenzenweger, M. F., Lane, M. C., Loranger, A. W., & Kessler, R. C. (2007). DSM-IV personality disorders in the National Comorbidity Survey Replication. Biological psychiatry, 62(6), 553-564.
2) Hasin, D. S., & Grant, B. F. (2015). The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Waves 1 and 2: review and summary of findings. Social psychiatry and psychiatric epidemiology, 50(11), 1609-1640.
3) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
4) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
5) Weinbrecht, A., Schulze, L., Boettcher, J., & Renneberg, B. (2016). Avoidant personality disorder: a current review. Current psychiatry reports, 18(3), 29.