AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), avoidant personality disorder (APD) is characterized by a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.¹ Children who meet the criteria for APD are often described as being extremely shy, inhibited in new situations, and fearful of disapproval and social rejection. The degree of the symptoms and impairment is well beyond the trait of shyness that is present in as many as 40% of the population. Similar to other personality disorders, the condition becomes a major component of a person's overall character and a central theme in an individual's pattern of relating to others. Like other personality disorders, the diagnosis is rarely made in individuals younger than 18 years, even if the criteria are met. The literature regarding childhood APD is extremely limited.

More information is known about social phobia (also known as social anxiety disorder) in children, which has many overlapping features with APD.

Pathophysiology

APD 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 Approximately 10% of toddlers have been found to be habitually fearful and withdrawn when exposed to new people and situations.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 the amygdala and other areas of the brain's limbic system, which, in affected individuals, is postulated to have a lower threshold of arousal and a more pronounced response when activated. Dysregulation in the brain's dopamine system has also been found to be associated with adult social anxiety disorder.

Frequency

United States

The frequency of APD in children is unknown because current psychiatric practice is to avoid labeling children and adolescents with personality disorders and to describe their traits instead. However, in the adult general population, the prevalence is estimated to be 2.1–2.6%.² Among adults receiving outpatient psychiatry treatment, the rate of APD is reported to be 14.7%.

International

The international frequency has not been studied in children, although a twin study of young adults found an APD rate of 1.4% in men and 2.5% in women.

Mortality/Morbidity

• School refusal and poor performance: As many as one third of children who refuse to go to school may have significant social anxiety.
• Conduct problems and oppositional behavior: Many children 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 APD often have few friends and often refuse social overtures as children, behavior patterns that persist through adolescence and adulthood.
• Lack of involvement in social and nonsocial activities: Patients with APD demonstrate lower levels of participation in athletics, extracurricular activities, and hobbies than children with depression or other personality disorders.

Race

The frequency of APD in children of different races has not been studied.

Sex

APD is estimated to be equally common in males and females.

Age

APD 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.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Avoidant personality disorder (APD) is a clinical diagnosis based on history provided by the child and caretakers combined with direct behavioral observation and mental status examination. According to the DSM-IV, criteria for diagnosis of APD in adults are met when a patient exhibits 4 or more of the behaviors below. No formal modification has been made for children. However, physicians should use caution when applying DSM-IV criteria, because overdiagnosis is a risk in adolescents.
• • Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection (For children, the DSM-IV reference to occupational activities can apply to school. Children with APD 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 APD is not used; however, social phobia is mentioned.
• For patients with a suspected diagnosis of APD, 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 and caretakers for their own psychiatric conditions may improve the outcome in the referred child.
• Unlike milder forms of developmental shyness, children with APD or social anxiety disorder do not easily adjust to people in new situations.

Physical

• No specific physical examination findings are associated with APD.
• Assess the patient's hearing acuity as part of a general screening.
• ADP may be more common in patients who have disfiguring physical conditions or limiting chronic illnesses.
• There may be an association between APD and motor impairment in children.
• In adults, a link has been found between APD and obesity.

Causes

• The exact cause of APD is unknown.
• The disorder may be related to temperamental factors that are inherited. 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. Components of this temperament have been identified in infants as young as 4 months.
• Genetic factors have been hypothesized to cause APD and social phobia because both conditions are found more frequently in certain families. A recent twin study of Norwegian young adults found a 35% genetic effect for APD; the majority (83%) of these genes are also related to other personality disorders.³
• Environmental factors also play in role in APD. Parenting behaviors, such as low parental affection or nurturing, were associated with an elevated risk of APD when these children reached adulthood.⁴ 
• Retrospective studies of adults with APD report high levels of childhood emotional abuse (61%).⁵ 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.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

• Panic disorder with agoraphobia
• Dependent personality disorder
• Schizoid personality disorder
• Communication disorders
• Generalized social anxiety disorder: Whether avoidant personality disorder [APD] and generalized social anxiety disorder are distinct entities or are different points along a common spectrum is still under debate.⁶ Current evidence suggests that although a high degree of overlap is observed, some qualitative distinctions remain.

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• No specific laboratory tests are helpful in the diagnostic workup of patients with avoidant personality disorder (APD).

Imaging Studies

• No specific imaging studies are helpful in the workup of patients with APD. 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 designed for the quantitative assessment of social anxiety in pediatric populations, such as the Liebowitz Social Anxiety Scale for Children and Adolescents.⁷

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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.

Drug Category: 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.

Drug Category: 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.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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.

In/Out Patient Meds

• 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

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal 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.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4^th 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. 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].

Article Last Updated: Mar 4, 2008