Avoidant personality disorder 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 2.12.6%.[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. History 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. Physical 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. Causes 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. Differential Diagnoses Anxiety Disorder: Generalized Anxiety Anxiety Disorder: Panic Disorder Anxiety Disorder: Separation Anxiety and School Refusal Anxiety Disorder: Social Phobia and Selective Mutism Hearing Impairment Mood Disorder: Depression Pervasive Developmental Disorder Pervasive Developmental Disorder: Autism Laboratory Studies

No specific laboratory tests are helpful in the diagnostic workup of patients with avoidant personality disorder. Imaging Studies

No specific imaging studies are helpful in the workup of patients with avoidant personality disorder. Routine brain CT scanning or MRI without focal neurologic signs are not indicated. Other Tests Young children should receive an audiology examination to rule out hearing problems. Clinicians may want to consider using rating scales or standardized diagnostic interviews designed for the quantitative assessment of personality disorders and other psychiatric disorders. Medical Care

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

Consultations

A complete 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 avoidant personality disorder to participate in as many social activities as can be tolerated. In children, encourage parents to help their child confront their fears without setting them up for repeated failure. Some individuals find that social encounters can be better tolerated and even enjoyed if they have a specific job or role to play. Medication Summary

No medications have been specifically tested or approved by the US Food and Drug Administration (FDA) for individuals with avoidant personality disorder. 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 avoidant personality disorder. Selective serotonin reuptake inhibitors Class Summary

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 avoidant personality disorder, 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 young adult 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% vs 2% on placebo) in short-term studies of children and young adults with depressive and anxiety disorders. Current recommendations include close monitoring of suicidality when starting or increasing any antidepressant. This potential risk is debated within the mental health community. View full drug information 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. Benzodiazepines Class Summary

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. View full drug information Clonazepam (Klonopin)

Used clinically to treat social anxiety, 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. Further Inpatient Care

Inpatient care is rarely required. Further Outpatient Care Referral to a psychiatrist or other mental health professional for diagnostic evaluation is indicated. Referral to a clinician trained in behavioral or cognitive-behavioral therapy can be beneficial.[10] 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). Group therapy 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 someone 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 avoidant personality disorder 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 Although avoidant personality disorder is often considered to be a chronic condition, significant improvement can occur with many individuals, especially with treatment.

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 avoidant personality disorder 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 avoidant personality disorder as adults.[11] 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 avoidant personality disorder, other social anxiety disorders, and parental styles that may be more helpful to children with avoidant personality disorder. 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.