Continuing Education Activity

Avoidant personality disorder is a chronic and pervasive maladaptive behavioral pattern. The onset is insidious and affects all aspects of the individual's life. This activity reviews the evaluation and the management of avoidant personality disorder and highlights the role of the interprofessional team in managing patients with this condition.

Objectives:

• Describe the postulated etiologies and risk factors that increase the diathesis for avoidant personality disorder.
• Identify the list of differential diagnoses for avoidant personality disorder.
• Outline the typical presentation of a patient with avoidant personality disorder.
• Explain the importance of improving care coordination amongst the interprofessional team to enhance the delivery of care for patients with avoidant personality disorder.

Introduction

In the 5th century B.C., Hippocrates offered his hypothesis regarding the origin of behavior with his humoral theory, postulating temperament was derived from the heterogeneous balance of the four distinct humors in the body. The four humors consisted of black bile - melancholic, yellow bile - irritable, phlegm - apathetic, and blood - sanguine. The humors and their subsequent temperaments supposedly embodied the elements of earth, fire, water, and air, respectively.[1] References to this initial nascent personality classification would be observed throughout antiquity up until the 20 century. The first nosological listing of personality types manifested with the creation of the diagnostic and statistical manual of mental disorders (DSM) I in 1952, in which seven distinct personality types were identified. This initial list was modified in subsequent editions of DSM, ultimately precipitating in the ten personality disorders, evident in the current DSM (DSM V - 2013).[2] 

These ten disorders are further categorized into three clusters – clusters A, B, and C. Cluster A contains paranoid, schizoid, and schizotypal. Cluster B consists of antisocial, histrionic, narcissistic, and borderline personality disorders. And cluster C includes avoidant, dependent, and obsessive-compulsive personality disorders. Personality disorders can be described as chronic life long maladaptive behavior patterns that are inflexible and pervasive, infiltrating all aspects of an individual’s life. Of salience for this review will be avoidant personality disorder (AVPD). AVPD was first introduced in the psychiatric nosology in DSM III in 1980. It is associated with an overly sensitive hyper-vigilant temperament, with a general longing to relate to others.[3] Sentiments regarding the formal designation of AVPD have been mixed, as some essentially view it as a more severe variant of social anxiety disorder (SAD).

Etiology

Genetic predisposition, infantile temperament, early childhood environment, and attachment style have all been postulated to play a role in the development of AVPD. The heritability coefficient for AVPD has been estimated to be 0.64.[4] Infantile temperament traits associated with a greater diathesis for AVPD include rigidity, hypersensitivity, low novelty seeking, high harm avoidance, and overactive behavioral inhibition.[5][6] 

Studies reveal that the dynamic relationship between temperament and attachment can further exacerbate the development of AVPD. This phenomenon manifests as the already minimally expressive infant’s distress is met with dismissive responsiveness from the caregiver, potentiating maladaptive behavior patterns.[7] These early interactions with caregivers result in fear of intimacy and trust, further engendering a state of hypervigilance. Ultimately, these negative schemas precipitate in avoidant coping strategies to obviate perceived prospective distress. Other pertinent factors include minimal parental encouragement, caregiver guilt-engendering, neglect, and abuse.

Epidemiology

Some experts question the validity of AVPD as an independent psychiatric manifestation rather than a disorder within the spectrum of anxiety-related pathology. Nonetheless, studies investigating the prevalence of this “questionable” disorder reveal rates ranging from 1.5% to 2.5%, with women being slightly more predisposed towards the development of AVPD.[8][9]

History and Physical

An inferiority complex coupled with a coexisting fear of rejection are the quintessential features of AVPD. Behaviorally, this manifests as widespread avoidance of social interaction, which is ultimately the salient diagnostic feature of AVPD. This intense aversion towards rejection leads to an excessive suppression of affective expression, resulting in extreme schizoid-like introversion. Often this terrible dread of rejection emanates from a repeated history of disappointing relationships of which the patient places the onus on him/herself, thus further diminishing self-esteem. This poor self-concept is more descriptively identified as a state of malignant self-regard (MSR). MSR further exacerbates feelings of shame, personal inadequacy, alexithymia, and perfectionism, and can also be observed in masochistic, self-defeating, depressive, and vulnerable narcissistic personalities.[3]

Evaluation

The initial interview with the avoidant patient will prove a challenge for the clinician. These patients are often reticent and laconic. Their constant fear of the potential embarrassment of 'saying something stupid' will disrupt the interview process. The interviewer must use tact to create a therapeutic alliance in which the patient feels confident enough to be forthcoming.

The categorical identification of AVPD in DSM-V implements the following diagnostic criteria:

Feelings of inadequacy, a pervasive pattern of social inhibition, and hypersensitivity to negative evaluation are present in a variety of contexts, beginning by early adulthood as indicated by 4 (or more) of the following:

1. Avoidance of activities related to an occupation that involve significant interpersonal contact due to fears of such issues as disapproval, criticism, or rejection.
2. Do not want to get involved with people unless they are sure of being liked.
3. Displays restraint within intimate relationships because of the fear of being ridiculed or shamed.
4. Is preoccupied with being rejected or criticized or in normal social situations.
5. Shows inhibition in new interpersonal situations because of feelings of inadequacy.
6. Views self as socially inept, personally unappealing, and inferior to other people.
7. Is unusually reluctant to take personal risks or engage in new activities because they may prove embarrassing.

The alternative dimensional model of AVPD identifies the internalization of distress, high levels of negative affectivity, behavioral inhibition and avoidance, and low levels of extraversion as salient diagnostic features.[10][11]

Treatment / Management

As with most personality disorders not included within cluster B, little to no research has been conducted to treat AVPD.[12] With this antecedent noted, post hoc analyses of studies investigating social anxiety disorder (SAD), with comorbid AVPD, indicate the potential benefit of cognitive-behavioral therapeutic (CBT) approaches to alleviate AVPD symptomatology.[13] 

CBT emphasizes the acknowledgment of negative automatic thoughts and how these thoughts can negatively influence behavior. This enlightenment is then followed by the implementation of prosocial behavior to correct the aforementioned dysfunctional schemas. Some experts believe interpersonal therapy (ITP) can be beneficial for overcoming social anxiety and developing trust. Although no FDA approved pharmacologic agent exists for the treatment of AVPD, anecdotal reports reveal the improvement of symptomatology following administration of psychotropics indicated for SAD, such as serotonin-specific reuptake inhibitors.[14] Furthermore, treating comorbid psychiatric illnesses will undoubtedly improve the patient’s quality of life.

Differential Diagnosis

As mentioned previously, AVPD was initially believed to represent a classification within the spectrum of pathological anxiety. Experts postulated that the phenomenology of AVPD could only exist in parallel with SAD; however, this assumption has since been dispelled, as roughly two-thirds of individuals with AVPD do not meet the standard criteria for SAD.[15] Shared vulnerability factors and common diagnostic criteria result in similar clinical presentations with other cluster C disorders, such as dependent personality disorder (DPD).[16] Although undoubtedly similar, the underlying foundational anxiety and desire for physical proximity in DPD result from a fear of abandonment, whereas ruminations of possible rejection consume those with AVPD.[3] 

The pervasive isolation witnessed in both AVPD and schizoid personality disorder can be diagnostically differentiated by contrasting the active-detachment of AVPD against the schizoid trait of passive-detachment. The former constitutes a state of "actively" avoiding social engagement with the impetus to circumvent rejection, whereas the latter ambivalent "passive" isolation precipitates from a complete lack of interest. Furthermore, those who have schizoid personality disorder are insensitive to social rejection and indifferent to interpersonal engagement.[3] In effect, behavioral patterns of AVPD can mimic varying pathologies. Thus, to ensure the diagnosis's veracity, clinicians will be wise to investigate the underlying impetus of behavioral manifestations.

Prognosis

AVPD is considered to be a chronic disorder, as implied by its designation within the family of personality disorders. However, some studies have suggested that, with time and treatment, a subset of those diagnosed with AVPD will eventually no longer meet diagnostic criteria. Specifically, one study revealed stability of diagnosis, ten years after the initial diagnosis, estimated to be 0.51.[17] 

Although this possibility of expiation from the disorder engenders hope, evaluations of those still meeting the diagnostic threshold of AVPD reveal minimal to nonexistent symptom diminishment.[18] The prognosis for this latter group is not hopeful. Research indicates that those with AVPD are more likely to be unemployed, less educated, single, and more likely to be on disability when compared to controls.[19] Persons with AVPD are also more likely to express worse physical health, frequent doctor visits, and more significant mental distress.[20]

Complications

Avoidant personality behavior patterns generally engender further psychiatric comorbidities and a general lack of dissatisfaction with life. It is not uncommon for someone with AVPD to suffer from depression, substance abuse, and eating disorders. This discontent is represented statistically as those with AVPD have a higher incidence of suicidal ideation and suicide attempts.[15] 

Less obvious but no less serious, the aforementioned malignant self-regard experienced by the avoidant patient can lead to a dysfunctional perfectionism, which can precipitate increased diathesis for postpartum depression.[21] Because of these detrimental complications, early identification of AVPD with subsequent intensive intervention is paramount.

Deterrence and Patient Education

Insidious in nature, AVPD is a chronic and pervasive disorder, without a defining inciting event or distinguishable time of onset. Recommendations for deterrence are relegated to caregivers and entail providing a nurturing and encouraging childhood environment. Psychoeducation of the social-psychological aspects of AVPD can be profoundly insightful, ultimately leading to fruitful behavioral adaptations.

Enhancing Healthcare Team Outcomes

The prompt identification and management of AVPD are paramount if the patient is to lead a fruitful and satisfying life. This goal can only be accomplished with a quality dynamic between the interprofessional team. Most likely, this disorder will require not only pharmacological intervention but also intense psychotherapy and unconditional support. Staff will need to be available around the clock in the event of emergent decompensation. A well functioning team will consist of a psychiatrist, psychologist, social worker, nurses, and medical assistants.