Background
According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), avoidant personality disorder (APD) is characterized by a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.[1] Individuals who meet the criteria for avoidant personality disorder are often described as being extremely shy, inhibited in new situations, and fearful of disapproval and social rejection. The intensity of the symptoms and level of impairment is beyond that which occurs with the trait of shyness that is present in as many as 40% of the population.
Similar to other personality disorders, avoidant personality disorder becomes a major component of a person's overall character and a central theme in an individual's pattern of relating to others. Also similar to other personality disorders, the diagnosis is rarely made in individuals younger than 18 years, even if the criteria are met. The literature regarding childhood avoidant personality disorder is extremely limited.
More information is known about social phobia (also known as social anxiety disorder) which has many overlapping features with avoidant personality disorder. Indeed, some experts contend that avoidant personality disorder is a variant of social anxiety disorder while others contend that there are enough differences to justify 2 separate diagnoses.
Case study
A 35-year-old computer programmer presents for treatment at the urging of his new girlfriend whom he met online. He describes himself as being painfully shy since childhood. There is no history of language delay, odd interests, or unawareness of social cues. On the contrary, he tends to overinterpret cues, believing that he is being negatively viewed by others. He has always had difficulty forming close friendships, not because of a lack of desire but because of an intense fear of rejection and disapproval. He endured adolescence with difficulty as his self-esteem dropped. In college, he became absorbed in his studies and avoided most social encounters because they were so difficult for him. After graduation, he looked for work that would minimize social interaction and opportunities to be judged by others. He did manage to meet his current girlfriend through a social networking website but she complains that he does not relate to her in an intimate manner.
Pathophysiology
Avoidant personality disorder is closely linked to a person's temperament. Approximately 10% of toddlers have been found to be habitually fearful and withdrawn when exposed to new people and situations. This trait appears to be stable over time. Social anxiety is hypothesized to involve dysfunction in the amygdala and its connections. Dysregulation in the brain's dopamine system has also been found to be associated with adult social anxiety disorder. Some of the genes related to the personality trait of introversion, such as brain derived neurotrophic factor (BDNF), are likely related to disorders such as avoidant personality disorder. Evidence shows that some of the risk genes for avoidant personality disorder are shared with schizoid personality disorder[2] and social anxiety disorder[3] .
Epidemiology
Frequency
United States
In the general adult population, the prevalence of avoidant personality disorder is estimated to be 2.1–2.6%.[4] Among adults receiving outpatient psychiatry treatment, the rate has been reported to be 3.6%.[5]
International
A twin study of young adults found an avoidant personality disorder rate of 1.4% in men and 2.5% in women.[3]
Mortality/Morbidity
- School refusal and poor performance: Among children, many who refuse to go to school may have significant social anxiety.
- Conduct problems and oppositional behavior: Many individuals with severe social anxiety refuse to participate in social activities and may have behavioral outbursts or panic attacks when placed in a social situation.
- Poor peer relations: Patients with avoidant personality disorder often have few friends and often refuse social invitations.
- Lack of involvement in social and nonsocial activities: Patients with avoidant personality disorder demonstrate lower levels of participation in athletics, extracurricular activities, and hobbies than those with depression or other personality disorders. They may avoid employment or work-related activities that involve too much social interaction.
- Substance abuse: Alcohol and drug abuse often coexist with significant social anxiety.
- Major depression: Major depression can also develop among individuals with avoidant personality disorder.
Race
The frequency of avoidant personality disorder across different races has not been systematically studied.
Sex
Avoidant personality disorder is estimated to be equally common in males and females.
Age
Avoidant personality disorder is not usually diagnosed in individuals younger than 18 years; however, most patients report an onset in childhood or adolescence, and many report continued social anxiety throughout their lives.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text revision. Washington, DC: American Psychiatric Association; 2000.
Kendler KS, Aggen SH, Czajkowski N, Roysamb E, Tambs K, Torgersen S, et al. The structure of genetic and environmental risk factors for DSM-IV personality disorders: a multivariate twin study. Arch Gen Psychiatry. Dec 2008;65(12):1438-46. [Medline].
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].
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].
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[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].
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].
Beidel DC, Turner SM. Shy Children, Phobic Adults: The Nature and Treatment of Social Phobia. Washington, DC: American Psychological Association; 1998.
Cox BJ, Pagura J, Stein MB, Sareen J. The relationship between generalized social phobia and avoidant personality disorder in a national mental health survey. Depress Anxiety. 2009;26(4):354-62. [Medline].
Millon T. Modern Psychopathology: A Biosocial Approach to Maladaptive Learning and Functioning. Philadelphia, PA: WB Saunders; 1969.
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].
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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