eMedicine Specialties > Psychiatry > Adult

Avoidant Personality Disorder: Follow-up

Author: David C Rettew, MD, Director, Pediatric Psychiatry Clinic, Fletcher Allen Health Care; Associate Professor of Psychiatry and Pediatrics, University of Vermont College of Medicine
Coauthor(s): Michael S Jellinek, MD, President, Newton-Wellesley Hospital; Alicia C Doyle, University of Vermont College of Medicine
Contributor Information and Disclosures

Updated: Mar 4, 2008

Follow-up

Further Inpatient Care

Inpatient care is rarely required.

Further Outpatient Care

  • Referral to a child and adolescent psychiatrist or behavioral/developmental pediatrician for diagnostic evaluation is indicated.
  • Referral to a clinician trained in behavioral or cognitive-behavioral therapy can be beneficial.8 Components of this type of therapy include education, social skills training, relaxation training, rewards for social behavior, slowly graduated exposure to feared situations, and helping the child correct distorted thoughts during feared encounters (real or simulated).
  • School-based treatments, including social skills groups, may be effective.
  • Continue monitoring medication dose and adverse effects.
  • Encourage parents and patients to confront feared situations as tolerated. Supporting additional social interaction in activities in which the child feels competent (eg, sports, art, music) can increase the chance of success.
  • Watch for the emergence of other psychiatric conditions, particularly major depression and substance abuse.

Inpatient & Outpatient Medications

  • Although medications are not often used in cases of APD without other comorbid conditions, improvement has been observed in patients with social phobia using SSRIs, SNRIs, benzodiazepines, MAOIs, and some anticonvulsants.
  • Avoid caffeine, which may trigger anxiety symptoms.

Deterrence/Prevention

  • Current studies are underway to assess the possibility of preventing social anxiety disorders in shy, inhibited children who do not yet meet the criteria for a psychiatric diagnosis.
  • Reducing parental overprotection and displays of parental anxiety may be beneficial in helping a child to manage his or her anxiety more effectively.

Complications

  • Social phobia
  • Major depression
  • Substance abuse
  • Long-term difficulties in social and occupational functioning

Prognosis

  • No long-term studies of children and adolescents with APD are available.
  • Social anxiety often precedes the onset of adolescent depression and alcohol abuse.
  • Onset of social phobia in a child younger than 11 years can be associated with continued symptoms into adulthood.
  • Examinations of adults with APD indicate that childhood lack of involvement with peers and failure to engage in structured activities may persist through adolescence and adulthood. Conversely, adults who have had positive achievements and interpersonal relationships during childhood and adolescence were more likely to remit from APD as adults.9
  • Children aged 2 years described as being very fearful and withdrawn in new situations were found to have higher levels of social anxiety in adolescence.

Patient Education

  • Encourage caretakers to learn as much as they can about APD, other social anxiety disorders, and parental styles that may be more helpful to children with APD.
  • Instruct families to encourage patient exposure to feared situations in a carefully planned and supportive manner when a good possibility of the patient being able to tolerate the situation exists.
  • For excellent patient education resources, visit eMedicine's Mental Health and Behavior. Also, see eMedicine's patient education article School Refusal.

Miscellaneous

Medicolegal Pitfalls

  • Failure to diagnose other concurrent mental health diagnoses
  • Failure to inform the patient and family about possible adverse effects of medications

Special Concerns

  • Differentiation between avoidant personality disorder (APD) or social phobia and other mental health diagnoses can be difficult. Key components of APD that can help differentiate from other diagnoses include the following:
    • Ability to form social relationships (compared with children with autism-spectrum disorders)
    • Desire for closeness that is impeded by anxiety (compared with children with schizoid personality disorder, some children with autistic spectrum disorders who prefer to be alone, and children who are socially withdrawn because of depression)
  • Selective mutism (ie, when a child refuses to speak in certain situations despite an ability to do so) is likely a variant of social phobia or APD.
  • Cultural and ethnic differences regarding the appropriateness of shy and avoidant behaviors are recognized. In addition, individuals from other countries who are experiencing difficulties with assimilation and language barriers can be mistaken as being very shy and avoidant.
 


More on Avoidant Personality Disorder

Overview: Avoidant Personality Disorder
Differential Diagnoses & Workup: Avoidant Personality Disorder
Treatment & Medication: Avoidant Personality Disorder
Follow-up: Avoidant Personality Disorder
References
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References

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.

  2. Grant BF, Hasin DS, Stinson FS, et al. Prevalence, correlates, and disability of personality disorders in the United States: results from the national epidemiologic survey on alcohol and related conditions. J Clin Psychiatry. Jul 2004;65(7):948-58. [Medline].

  3. Reichborn-Kjennerud T, Czajkowski N, Neale MC, et al. Genetic and environmental influences on dimensional representations of DSM-IV cluster C personality disorders: a population-based multivariate twin study. Psychol Med. May 2007;37(5):645-53. [Medline].

  4. Johnson JG, Cohen P, Chen H, Kasen S, Brook JS. Parenting behaviors associated with risk for offspring personality disorder during adulthood. Arch Gen Psychiatry. May 2006;63(5):579-87. [Medline].

  5. Rettew DC, Zanarini MC, Yen S, et al. Childhood antecedents of avoidant personality disorder: a retrospective study. J Am Acad Child Adolesc Psychiatry. Sep 2003;42(9):1122-30. [Medline].

  6. Rettew DC. Avoidant personality disorder, generalized social phobia, and shyness: putting the personality back into personality disorders. Harv Rev Psychiatry. Dec 2000;8(6):283-97. [Medline].

  7. Masia CL, Klein RG, Liebowitz MR. The Liebowitz Social Anxiety Scale for Children and Adolescents (LSAS-CA). New York, NY: NYU Child Study; Center; 1999.

  8. [Best Evidence] Emmelkamp PM, Benner A, Kuipers A, et al. Comparison of brief dynamic and cognitive-behavioural therapies in avoidant personality disorder. Br J Psychiatry. Jul 2006;189:60-4. [Medline]. [Full Text].

  9. Skodol AE, Bender DS, Pagano ME, et al. Positive childhood experiences: resilience and recovery from personality disorder in early adulthood. J Clin Psychiatry. Jul 2007;68(7):1102-8. [Medline].

  10. Beidel DC, Turner SM. Shy Children, Phobic Adults: The Nature and Treatment of Social Phobia. Washington, DC: American Psychological Association; 1998.

  11. Kagan J. Galen's Prophecy: Temperament in Human Nature. New York, NY: Basic Books; 1994.

  12. Millon T. Modern Psychopathology: A Biosocial Approach to Maladaptive Learning and Functioning. Philadelphia, PA: WB Saunders; 1969.

  13. Schwartz CE, Snidman N, Kagan J. Adolescent social anxiety as an outcome of inhibited temperament in childhood. J Am Acad Child Adolesc Psychiatry. Aug 1999;38(8):1008-15. [Medline].

  14. Westen D, Shedler J, Durrett C, et al. Personality diagnoses in adolescence: DSM-IV axis II diagnoses and an empirically derived alternative. Am J Psychiatry. May 2003;160(5):952-66. [Medline].

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Further Reading

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Keywords

avoidant personality disorder, APD, childhood APD, avoidant disorder, social phobia, social anxiety disorder, personality disorder, SSRIs, limbic system, anxiety disorder, social disorder, shy, shyness, school refusal, oppositional behavior, depression, substance abuse, child neglect, child abuse, obesity, posttraumatic stress disorder, generalized social anxiety disorder

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Contributor Information and Disclosures

Author

David C Rettew, MD, Director, Pediatric Psychiatry Clinic, Fletcher Allen Health Care; Associate Professor of Psychiatry and Pediatrics, University of Vermont College of Medicine
David C Rettew, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry and American Psychiatric Association
Disclosure: Nothing to disclose.

Coauthor(s)

Michael S Jellinek, MD, President, Newton-Wellesley Hospital
Michael S Jellinek, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, and American Pediatric Society
Disclosure: Nothing to disclose.

Alicia C Doyle, University of Vermont College of Medicine
Disclosure: Nothing to disclose.

Medical Editor

Carol Diane Berkowitz, MD, Executive Vice Chair, Department of Pediatrics, Professor, Harbor-University of California at Los Angeles Medical Center
Carol Diane Berkowitz, MD is a member of the following medical societies: Alpha Omega Alpha, Ambulatory Pediatric Association, American Academy of Pediatrics, American College of Emergency Physicians, American Medical Association, American Pediatric Society, and North American Society for Pediatric and Adolescent Gynecology
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

CME Editor

Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Medical Women's Association, American Psychiatric Association, and American Society for Adolescent Psychiatry
Disclosure: Nothing to disclose.

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

 
 
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