Journal of Affective Disorders 54 (1999) 277282

Research report

Avoidant personality in social phobia and panicagoraphobic

disorder: a comparison
a,
a
a
a
a
Giulio Perugi *, Stefano Nassini , Cristina Socci , Michele Lenzi , Cristina Toni ,
a
b
Elisa Simonini , Hagop S. Akiskal
a

Institute of Psychiatry, University of Pisa, Via Roma 67, 56100 Pisa, Italy
International Mood Disorder Center, Department of Psychiatry, University of California at San Diego, La Jolla, USA
Received 18 November 1997; received in revised form 10 February 1999; accepted 22 March 1999

Abstract
Background: Avoidant personality disorder (APD) is generally believed to be related to social phobia (SP), especially to
generalized subtype. However, it has also been reported to be prevalent in panic disorderagoraphobia (PDA). In the present
investigation, we wished to explore whether APD in each of these disorders has discriminatory features. Method: We studied
71 SP and 119 PDA patients with state-of-the-art clinical instruments based on DSM-III-R. Results: The pattern of social
avoidance in SP was more pervasive: it was characterized by a higher level of interpersonal sensitivity and greater severity,
associated with psychopathology as well as a higher rate of Axis I comorbidity. By contrast, avoidance of non-routine
situations characterized APD occurring in the setting of PDA. Limitations: Differences in inclusion criteria and comorbidity
rates, as well as overlap between different operational disorders, may have influenced our findings. Conclusion: ADP is
operationally broad, and avoidant as a specifier of a personality type is insufficiently precise. ADP captures avoidant traits
which appear secondary to a core dimension such as interpersonal sensitivity but is basically a heterogeneous
condition influenced by the nature of comorbid Axis I disorders. 1999 Elsevier Science B.V. All rights reserved.
Keywords: Avoidant personality; Interpersonal sensitivity; Social phobia; Panic disorder; Agoraphobia

1. Introduction
Avoidant personality disorder (APD) has been
reported to frequently co-occur with social phobia
(SP) (Alnaes and Torgersen, 1988; Brooks et al.,
*Corresponding author. Tel.: 1 39-50-592-479; fax: 1 39-5021-581.

1989; Klass et al., 1989; Schneier et al., 1991;

Herbert et al., 1992, Holt et al., 1992; Turner et al.,
1992) as well as with panic disorder irrespective of
the presence of agoraphobia (PDA) (Renneberg et
al., 1992; Jansen et al., 1994; Noyes et al., 1995).
The overlap is particularly extensive between APD
and SP of the generalized subtype (Schneier et al.,
1991; Turner et al., 1991; Herbert et al., 1992, Holt

0165-0327 / 99 / $ see front matter 1999 Elsevier Science B.V. All rights reserved.
PII: S0165-0327( 99 )00062-2

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G. Perugi et al. / Journal of Affective Disorders 54 (1999) 277 282

et al., 1992); although APD is more severe than SP

in terms of social anxiety and social functioning
(Widiger, 1992), few qualitative differences separate
these two conditions (Herbert et al., 1992; Holt et al.,
1992; Turner et al., 1992). Moreover, both pharmacological (Deltito and Stam, 1989; Liebowitz et al.,
1991) and behavioural (Brown et al., 1995) treatments have been shown equally effective in patients
with SP with and without APD. These findings
suggest that the two conditions might represent
different points on a continuum of severity (Herbert et al., 1992, p. 338) and some authors (Schneier
et al., 1991; Turner et al., 1992) have questioned
whether SP and APD are separate entities or the
same condition described from different perspectives. It is unclear whether the high overlap between
APD and SP would persist if recruitment for these
two disorders were conducted independently.
The association between SP and APD could be
further clarified by comparing APD with patients
selected on the basis of another anxiety disorder.
Jansen et al. (1995), comparing 32 patients with SP
and 85 patients with PDA, found similar rates of
APD (31.3 vs. 23.5, respectively); SP patients appeared to be more disturbed on Axis II, and APD
criterion 6 (fears being embarrassed) discriminated
SP the most from PDA on the item level. A major
limitation here was the fact that Axis I diagnoses
were not based on structured interview.
The aim of our study, which attempts to redress
the foregoing methodological shortcoming, was
twofold: (1) to evaluate the distribution of APD
according to DSM-III-R (APA, 1987) criteria in two
groups of patients with PD and SP; (2) to clarify the
question of the specificity of the co-presence of
APD, by means of a direct comparison of the clinical
features and the personality profile in the two groups
of patients.

2. Patients and methods

We selected 71 patients with SP and 119 with PD,
consecutively admitted to a long term treatment
program for anxiety disorders located with the
Institute of Psychiatry of the University of Pisa.
Information on Axis I diagnoses was obtained by
using the Structured Clinical Interview for DSM-III-

R-Upjohn version (SCID-UP, Spitzer and Williams,

1988). With the exception of simple phobia and
generalized anxiety disorder, subjects with current
(past 6 months) comorbidity with mood or other
anxiety disorders were not included. However, lifetime comorbidity with mood or other anxiety disorders was not excluded. Finally we excluded subjects who had a history of psychosis, organic mental
disorder or mental retardation, uncontrolled physical
disease or abnormal laboratory values.
Patients were assessed for DSM-III-R APD using
the APD section of the Structured Clinical Interview
for DSM-III-R Personality Disorder (SCID-II,
Spitzer et al., 1990). A specially constructed semistructured interview was also administered to investigate demographic features and longitudinal aspects
of the anxiety disorder (Perugi et al., 1995; Benedetti
et al., 1997). The interview lasted | 1.5 h and is
instituted by residents with extensive experience in
the diagnosis and treatment of anxiety disorders.
Patients self-evaluation was recorded on the Hopkins Symptoms Checklist (HSCL-90) (Derogatis et
al., 1973). The reliability of our methods has been
documented elsewhere (Perugi et al., 1998a).
Comparison between groups on continuous variables were analysed by Students t-test, and categorical variables by x 2 analysis. Because of multiple
comparisons only values of P , 0.01 can be considered significant.

3. Results
Patients with PDA and SP differed in terms of
mean age (respectively 36.1611.7 vs. 30.669.4, t 5
3.3, df 5 179, P 5 0.001), age at onset (28.7610.6
vs. 14.366.5, t 5 10.1, df 5 179, P 5 0.0001) and
gender distribution (males 5 39, 32.8% vs. 43,
60.6%; x 2 5 14.0, df 5 1, P 5 0.0002). As expected,
the rate of patients who received the co-diagnosis of
APD was higher in SP (n 5 50, 70.4%) compared
with PDA (n 5 45, 37.8%) ( x 2 5 18.9, df 5 1, P 5
0.0001).
Comparisons between demographic features and
comorbidity in APD patients with SP and PDA
showed several significant differences (Table 1).
Social phobic APD were younger, with earlier age at
onset, more often males, single and had a higher

G. Perugi et al. / Journal of Affective Disorders 54 (1999) 277 282

279

Table 1
Demographic characteristics and lifetime comorbidity in 50 SP patients and 45 PDA patients with APD

Age, mean (S.D.)

Age at onset, mean (S.D.)
Gender: Male, n (%)
Marital status, n (%)
Single
Married
Separated or divorced
Education, n (%)
University graduates
High school
Junior high school
Less than 7 years
Lifetime comorbidity, n (%)
Major depression
Bipolar disorder II
Obsessive compulsive disorder
Generalized anxiety disorder
Panic disorderagoraphobia
Social phobia
Simple phobia
Use of alcohol and / or sedatives
Separation anxiety

SP with APD
(n 5 50)

PDA with APD

(n 5 45)

t or x 2 (df)

29.3 (8.9)
12.7 (5.2)
31 (62.0)

36.7 (10.8)
29.8 (10.1)
12 (26.7)

3.67 (93)
10.34 (93)
11.93 (1)

0.0004
0.0001
0.0006

40 (80.0)
8 (16.0)
2 (4.0)

10 (22.2)
33 (73.3)
2 (4.4)

33.07 (2)

0.0001

6 (12.0)
31 (62.0)
13 (26.0)
0 (0.0)

2 (4.6)
12 (27.9)
17 (39.5)
12 (27.9)

22.53 (3)

0.0001

27 (54.0)
14 (28.0)
20 (40.0)
8 (16.0)
22 (44.0)

15 (33.3)
2 (4.4)
4 (8.9)
12 (26.7)

4.10 (1)
9.38 (1)
12.14 (1)
1.62 (1)

ns
0.002
0.0005
ns

7 (15.6)
9 (20.0)
5 (11.1)
20 (44.4)

0.48 (1)
4.22 (1)
0.06 (1)

ns
ns
ns

13 (26.0)
14 (28.0)
21 (42.0)

education level than PDA patients. SP patients by

contrast, showed a higher rate of comorbid Bipolar II
and obsessive compulsive disorder. While 44% of SP
showed lifetime comorbidity with PDA, only 15.6%
of PDA patients reported lifetime SP.
The comparison of the DSM-III-R diagnostic
criteria for APD (Table 2) showed that sensitivity to
criticism or disapproval, avoidance of activities that
involve significant interpersonal contact, and reticence in social situations because of a fear of saying
something inappropriate, were significantly more
frequent in the SP group, while avoidance of unusual situations appeared to be more represented in
PDA patients.
Concerning the self-evaluation scores on the
HSCL-90 (Table 3), the subjects with APD with SP
scored significantly higher values in SCL-90 factors,
except for Anxiety, Phobic Anxiety, Somatisation and Psychoticism that obtained similar mean
scores in the two groups. The greater severity of
APD with SP is confirmed by the scores of the items
on the Interpersonal Sensitivity factor. These patients obtained statistically significant higher mean

scores compared to PDA in all items, except feeling

uncomfortable about eating or drinking in public.

4. Discussion
Several limitations of this study need to be
recognized. Different inclusion criteria may have
influenced our comparison: social phobics were
recruited to have moderately severe symptoms, and
panic subjects were required to have had at least one
panic attack per week in the last month. A related
factor has to do with differences in lifetime comorbidity between the PDA and SP. A final constraint
generic to all diagnostic research based on postDSM-III-R criteria derives from the unavoidable
overlap between different operational disorders. The
present study represents an attempt to clarify
within these limitations the relationship between
anxiety and anxious personality disorders.
Our findings confirm that APD is not restricted to
SP, but is common among patients with PDA. High
frequencies of APD in PDA have been reported by

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G. Perugi et al. / Journal of Affective Disorders 54 (1999) 277 282

Table 2
DSM-III-R diagnostic criteria for avoidant personality disorder in PD and SP patients with APD

Is easily hurt by criticism

or disapproval.
Has no close friends or
confidant (or only one)
other than first-degree relatives.
Is unwilling to get involved
with people unless certain
of being liked.
Avoids social or occupational
activities that involve significant
interpersonal contact.
Is reticent in social situations
because of a fear of saying
something inappropriate or
foolish, or of being unable to
answer a question.
Fears being embarrassed by
blushing, crying, or showing
signs of anxiety in front of
other people.
Exaggerates the potential
difficulties, physical dangers,
or risks involved in doing
something ordinary but outside
his or her usual routine.

PDA with APD

(n 5 45)
n (%)

SP with APD
(n 5 50)
n (%)

37 (82.2)

50 (100.0)

9.71

0.002

29 (64.4)

37 (74.0)

1.02

ns

31 (68.9)

41 (82.0)

2.22

ns

24 (53.3)

46 (92.0)

18.26

0.0001

32 (71.1)

48 (96.0)

11.03

0.0009

35 (77.7)

41 (82.0)

0.26

ns

33 (73.3)

21 (42.0)

9.48

0.002

Reich et al. (1987) and Alnaes and Torgersen

(1988), and a comparable frequency of APD in PDA
patients (32%) was found by Renneberg et al.
(1992).
The main result of our study concerns the different
distribution of DSM-III-R criteria for APD diagnosis
in the two groups. The pattern of avoidance with SP
comorbidity is more pervasive and generalized,
depending on higher levels of interpersonal sensitivity and behavioural inhibition, probably as a result of
greater severity of the symptomatology and of a
higher rate of comorbidity with Axis I disorders.
Avoidance of unusual situations appears to be correlated with the presence of APD in PDA patients.
Criteria for APD have been partially modified in
DSM IV (APA, 1994). The last criterion has been
modified and refocused on embarrassing new activities. In our opinion the DSM IV criteria seem to
reflect a definition of APD closer to the profile of
traits presented by patients with primary Axis I

x 2 (df 5 1)

diagnosis of SP. This problem may be partially

clarified by studies on clinical populations selected
on the basis of a principal diagnosis of APD with
different sets of criteria.
The association between SP and APD does not
necessarily mean that APD is always a severe form
of SP. APD is also diagnosed, albeit less frequently,
in other anxiety disorders as well as in such conditions as Body Dysmorphic Disorder (Veale et al.,
1996), Atypical Depression (Perugi et al., 1998b),
Eating Disorders (Oldham et al., 1995). SP may
covary with APD, however, although the definitions
of the two disorders are quite similar, the one
emphasizes phobic symptoms and the other avoidant
traits and their interpersonal consequences. APD is
essentially a problem of relating to persons; social
phobia is largely a problem of performing situations
(Millon, 1991). For the present, there does not seem
to be a simple solution to this conceptual diagnostic
problem. Here, as elsewhere, the distinction between

G. Perugi et al. / Journal of Affective Disorders 54 (1999) 277 282

281

Table 3
HSCL-90 factors and items of interpersonal sensitivity in PD and SP patients with APD

HSCL-90 factors
Interpersonal sensitivity
Anxiety
Obsessioncompulsion
Depression
Paranoidism
Phobic anxiety
Somatization
Hostilityanger
Psychoticism
Items of interpersonal sensitivity
Feeling critical of others
Feeling shy or uneasy
with the opposite sex
Your feelings being
easily hurt
Feeling others do not understand
you or are unsympathetic
Feeling that people are
unfriendly or dislike you
Feeling inferior to others
Feeling uneasy when people are
watching or talking about you
Feeling very self-conscious
with others
Feeling uncomfortable about
eating or drinking in public

PDA with APD

(n 5 45)
Mean (S.D.)

SP with APD
(n 5 50)
Mean (S.D.)

1.25
1.58
1.39
1.63
1.06
1.24
1.36
0.84
0.76

2.37
1.84
1.97
2.10
1.64
1.25
1.02
1.24
1.16

(0.62)
(0.76)
(0.75)
(0.73)
(0.76)
(0.70)
(0.70)
(0.71)
(0.67)

2 7.60
2 1.58
2 3.81
2 4.14
2 3.51
2 0.01
2.19
2 2.64
2 2.00

0.0001
ns
0.0002
0.0001
0.0007
ns
ns
0.01
ns

0.85 (1.04)

1.62 (1.28)

2 3.22

0.002

0.80 (1.04)

2.42 (1.16)

2 7.14

0.0001

1.58 (1.27)

2.70 (1.01)

2 4.78

0.0001

1.13 (1.14)

2.30 (1.11)

2 5.05

0.0001

1.18 (1.19)
1.62 (1.39)

2.06 (1.33)
2.86 (1.11)

2 3.39
2 4.83

0.001
0.0001

1.40 (1.27)

2.86 (0.97)

2 6.34

0.0001

1.51 (1.24)

2.96 (0.88)

2 6.63

0.0001

1.22 (1.28)

1.54 (1.34)

2 1.18

ns

(0.81)
(0.80)
(0.70)
(0.77)
(0.86)
(0.84)
(0.81)
(0.75)
(0.71)

what is labelled personality (Axis II) and psychiatric

syndrome (Axis I) remains blurred (Akiskal, 1984;
Widiger, 1992).
In our view, ADP may be considered a heterogeneous condition whose boundaries are probably
influenced by the presence of an Axis I comorbid
disorder. As a corollary, we submit that the core
defining trait in APD might be interpersonal sensitivity, whereas in SP it is avoidance of social
situations, and in PDA avoidance of non-routine
situations. These considerations further suggest that
avoidant as a qualifier for a personality type is
insufficiently precise.

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