Avoidant Personality Disorder Clinical Presentation

• Avoidant personality disorder is a clinical diagnosis based on history combined with direct behavioral observation and mental status examination. According to the DSM-IV-TR, criteria for diagnosis of avoidant personality disorder in adults are met when a patient exhibits 4 or more of the behaviors below. No formal modification has been made for children.

  • Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection (For children, the DSM-IV-TR reference to occupational activities can apply to school. Children with avoidant personality disorder often have marked difficulty, especially with new classes, presentations in front of the class, and less-structured times such as recess or lunch.)
  • Is unwilling to get involved with people unless certain of being liked
  • Shows restraint within intimate relationships because of the fear of being shamed or ridiculed
  • Is preoccupied with being criticized or rejected in social situations
  • Is inhibited in new interpersonal situations because of feelings of inadequacy
  • Views self as socially inept, personally unappealing, or inferior to others
  • Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing
• In the Diagnostic and Statistical Manual for Primary Care, Child and Adolescent Version (DSM-PC), the diagnosis of avoidant personality disorder is not used; however, social phobia is mentioned.
• For patients with a suspected diagnosis of avoidant personality disorder, evaluating for the presence of other psychiatric disorders, particularly major depression, substance abuse, and other anxiety disorders, is extremely important. The possibility that a fear of involvement with people is based on a history of child abuse and neglect should be investigated.
• Because social anxiety disorders are often found in other family members, a family psychiatric history is beneficial. Treatment of parents, partners, and caretakers for their own psychiatric conditions may improve the outcome in the referred patient.

• No specific physical examination findings are associated with avoidant personality disorder.
• Assess the patient's hearing acuity as part of a general screening.
• Avoidant personality disorder may be more common in patients who have disfiguring physical conditions or limiting chronic illnesses.
• There may be an association between avoidant personality disorder and motor impairment in children.
• In adults, a link has been found between avoidant personality disorder and obesity.

Sample Mental Status Examination

The patient presents as a well-groomed man who seems somewhat nervous and unassertive. Eye contact is sporadic. He is cooperative with the evaluation process. Speech is soft but otherwise normal with regard to rate and articulation. Attention, concentration, fund of knowledge, and language function appear normal. Mood is described as nervous. Affect is slightly constricted. There is no suicidal or homicidal ideation. Thought process is logical and coherent and without loose associations. Thought content is negative for hallucinations or delusions. The patient does seem somewhat perseverative regarding the examiner's opinion of him. Insight and judgement are estimated as good. He is oriented in all 3 spheres. Recent and remote memory are intact.

• The exact cause of avoidant personality disorder is unknown.
• The disorder may be related to temperament and personality traits that are influenced by both genetic and environmental factors. Specifically, various anxiety disorders in childhood and adolescence have been associated with a temperament characterized by behavioral inhibition, including features of being shy, fearful, and withdrawn in new situations.^[6]
• Genetic factors have been hypothesized to cause avoidant personality disorder and social phobia. A twin study of Norwegian young adults found a 35% genetic effect for avoidant personality disorder; most (83%) of these genes are also related to other personality disorders.^[3]
• Environmental factors also play in role in avoidant personality disorder. Parenting behaviors, such as low parental affection or nurturing, were associated with an elevated risk of avoidant personality disorder when these children reached adulthood.^[7]
• Retrospective studies of adults with avoidant personality disorder report high levels of childhood emotional abuse (61%).^[8] However, physical abuse may be more closely linked with a diagnosis of another personality disorder or posttraumatic stress disorder (PTSD).
• A multifactorial model of causation is likely, with genetic and environmental factors interacting from infancy in various combinations.