eMedicine Specialties > Psychiatry > Adult

Avoidant Personality Disorder: Treatment & Medication

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

Treatment

Medical Care

Avoidant personality disorder (APD) alone is rarely a cause for inpatient psychiatric hospitalization. Evaluation and treatment can be conducted on an outpatient basis.

Consultations

A complete child/adolescent mental health evaluation is recommended, especially to evaluate for other anxiety disorders or depressive disorders.

Diet

No special diet is required.

Activity

Encourage patients with APD to participate in as many social activities as can be tolerated. After careful selection and child preparation, take care to ensure that the child is not set up for repeated failure or excessive anxiety. However, physicians should remember that parents of children with APD also often have personal social difficulties; these have the potential to create treatment obstacles. Some children find that social encounters can be better tolerated and even enjoyed if they have a specific role to play.

Medication

No medications have been specifically tested or approved by the US Food and Drug Administration (FDA) for children and adolescents with avoidant personality disorder (APD). Selective serotonin reuptake inhibiters (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) have been found to be effective for social anxiety disorder. In addition, some studies have reported that benzodiazepines, monamine oxidase inhibitors (MAOIs), and the anticonvulsant gabapentin are effective in the treatment of social anxiety in adults with APD.

Selective serotonin reuptake inhibitors

These agents initially block the presynaptic reuptake of serotonin, thereby allowing more of the neurotransmitter to be available in the synapse. Although no medications are approved by the FDA to treat APD, the SSRIs paroxetine (Paxil) and sertraline (Zoloft) and the SNRI venlafaxine (Effexor) are FDA-approved to treat social anxiety disorder.

SSRIs are greatly preferred over the other classes of antidepressants. Because the adverse effect profile of SSRIs is less prominent, improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with tricyclic antidepressants. Arrhythmia risk is especially pertinent in cases of overdose, and suicide risk must always be considered when treating a child or adolescent with mood disorder.

Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with SSRIs and SNRIs in the pediatric population.

All antidepressants now carry a black box warning regarding elevated rates of suicidal behavior (4% versus 2% on placebo) in short-term studies of children with depressive and anxiety disorders. Current recommendations include close monitoring of suicidality when starting or increasing any antidepressant. This potential risk is hotly debated within the research community.


Sertraline (Zoloft)

Zoloft and other SSRI medications are considered first-line treatment for APD and social phobia. Benefits of SSRIs include relatively high tolerance, ease of administration, and relative safety in overdose.

Adult

50 mg/d PO; may titrate upward (at intervals of at least 1 wk), not to exceed 200 mg/d PO

Pediatric

6-12 years: 12.5-25 mg/d PO initially, may titrate upward (at intervals of at least 1 wk), not to exceed 150 mg/d PO
13-17 years: 50 mg/d PO initially; may titrate upward (at intervals of at least 1 wk), not to exceed 200 mg/d PO

CYP450 2D6 substrate; coadministration with alcohol, cimetidine, phenothiazines, or warfarin may increase toxicity; highly protein bound, may displace other protein bound drugs (eg, warfarin); may inhibit TCAs metabolism

Documented hypersensitivity; concurrent administration with MAOIs or administration within 14 d of discontinuing MAOIs; administration with pimozide also contraindicated

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Gradually titrate dose to produce clinical effect and reduce adverse effects; common adverse effects include GI distress, irritability, insomnia, dizziness, fatigue, and sexual dysfunction; can precipitate mania in patients with bipolar disorder; inquire about history of bipolar disorder and monitor for signs of mania; abrupt discontinuation can lead to withdrawal symptoms

Benzodiazepines

These agents bind to a specific benzodiazepine receptor on the gamma-aminobutyric acid (GABA) receptor complex, thereby increasing GABA affinity for its receptor. They also increase the frequency of chlorine channel opening in response to GABA binding. GABA receptors are chlorine channels that mediate postsynaptic inhibition, resulting in postsynaptic neuron hyperpolarization. The final result is a sedative-hypnotic and anxiolytic effect. High-potency benzodiazepines are likely to be effective in treating social phobia in adults.


Clonazepam (Klonopin)

Used clinically to treat social anxiety in children and adolescents, although no controlled studies have been conducted in this population to document its efficacy. This medication is believed to work at the GABAa receptor in the brain, particularly the limbic areas.

Adult

0.25-6 mg/d PO, often in divided doses

Pediatric

0.01-0.04 mg/kg/d PO qd or divided bid/tid

Phenytoin or barbiturates may reduce effects; coadministration of CNS depressants increase toxicity

Documented hypersensitivity; severe liver disease; acute narrow-angle glaucoma

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Common adverse effects include sedation, drowsiness, and confusion; dependence and tolerance can develop with long-term use; adverse withdrawal effects can occur with abrupt cessation of use; excessive behavioral disinhibition has been reported

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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