Background
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM5), avoidant personality disorder (APD) is characterized by a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. [1, 2] 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. Whereas in social anxiety disorder, significant distress or impairment in social or occupational function is a part of the diagnostic criteria, [3, 4] in avoidant personality disorder, the degree of distress or impairment is not designated.
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 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 [5] and social anxiety disorder [6] .
Epidemiology
Frequency and Demographics
In the general adult population, the prevalence of avoidant personality disorder is estimated to be 2.1–2.6%. [7] Among adults receiving outpatient psychiatry treatment, the rate has been reported to be 3.6%. [8]
A twin study of young adults found an avoidant personality disorder rate of 1.4% in men and 2.5% in women. [6]
Avoidant personality disorder is estimated to be equally common in males and females.
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.
Mortality/Morbidity
See the list below:
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School refusal and poor performance: Among children, many who refuse to go to school may have significant social anxiety.
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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.
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Poor peer relations: Patients with avoidant personality disorder often have few friends and often refuse social invitations.
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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.
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Substance abuse: Alcohol and drug abuse often coexist with significant social anxiety.
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Major depression: Major depression can also develop among individuals with avoidant personality disorder.
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.
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.
For excellent patient education resources, visit eMedicineHealth's Mental Health Center. Also, see eMedicineHealth's patient education article School Refusal.
