Cluster C personality disorders include avoidant, dependent, and obsessive-compulsive personality disorders. Individuals with these disorders often appear anxious, fearful, or clingy (a mnemonic to help remember Cluster C disorders are the three C’s—cowardly, clingy, and compulsive). Avoidant personality disorders exhibit a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. Dependent personality disorders show a pattern of submissive and clinging behavior that evidence an excessive need to be taken care of. Lastly, obsessive-compulsive personality disorders manifest a preoccupation with orderliness, perfectionism, and control.

Avoidant Personality Disorder

People with avoidant personality disorder (AvPD) often consider themselves to be socially inept or personally unappealing and avoid social interaction for fear of being ridiculed, humiliated, rejected, or disliked. They often avoid becoming involved with others unless they are certain they will be liked. As the name suggests, the main coping mechanism of those with avoidant personality disorder (AvPD) is avoidance of feared stimuli.

Those affected display a pattern of severe social anxiety, social inhibition, feelings of inadequacy and inferiority, extreme sensitivity to negative evaluation and rejection, and avoidance of social interaction despite a strong desire for intimacy.

According to the DSM-5, avoidant personality disorder (AvPD) diagnosis refers to a widespread pattern of inhibition around people, feeling inadequate, and being very sensitive to negative evaluation. Symptoms begin by early adulthood and occur in a range of situations.

Figure 1. People with AvPD often have a negative perception of themselves.

Four of the following seven specific symptoms should be present:

• avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection
• 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 risk or to engage in any new activities because they may prove embarrassing

Differential Diagnosis

In contrast to social anxiety disorder, a diagnosis of AvPD also requires that the general criteria for a personality disorder are met. According to DSM-5, AvPD must be differentiated from similar personality disorders such as dependent, paranoid, schizoid, and schizotypal. But these disorders can also occur together; this is particularly likely for AvPD and dependent personality disorder. Thus, if criteria for more than one personality disorder are met, all can be diagnosed. There is also an overlap between avoidant and schizoid personality traits, and AvPD may have a relationship to the schizophrenia spectrum.

Comorbidity

AvPD is reported to be especially prevalent in people with anxiety disorders, although estimates of comorbidity vary widely due to differences in (among others) diagnostic instruments. Research suggests that approximately 10–50% of people who have panic disorder with agoraphobia have avoidant personality disorder, as well as about 20–40% of people who have social anxiety disorder. In addition, AvPD is more prevalent in people who have comorbid social anxiety disorder and generalized anxiety disorder than in those who have only one of the aforementioned conditions. Some studies report prevalence rates of up to 45% among people with generalized anxiety disorder and up to 56% of those with obsessive-compulsive disorder. Post-traumatic stress disorder is also commonly comorbid with avoidant personality disorder.

Epidemiology

Data from the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions indicates a prevalence rate of 2.36% in the American general population. It appears to occur with equal frequency in males and females.

Etiology

Figure 2. Childhood neglect is a risk factor for AvPD.

Causes of AvPD are not clearly defined, but appear to be influenced by a combination of social, genetic, and psychological factors. The disorder may be related to temperamental factors that are inherited.

Childhood emotional neglect (in particular, the rejection of a child by one or both parents) and peer group rejection are associated with an increased risk for its development; however, it is possible for AvPD to occur without any notable history of abuse or neglect.

Treatment

Treatment of avoidant personality disorder can employ various techniques, such as social skills training, psychotherapy, cognitive therapy, exposure treatment to gradually increase social contacts, group therapy for practicing social skills, and sometimes drug therapy.