Avoidant personality disorder (AvPD) is amongst the most frequent personality disorders (PDs) in both community and clinical samples with a large variety in severity. Those who are referred to specialized treatment show high burden of disease, with high degree of symptoms, low personality functioning, impaired social and work functioning, low quality of life and severe loneliness. Addtionally, there is a risk of chronicity due to low outcome and relapse after non-specialized treatment. AvPD is often called the neglected disorder because of little research and the big shortage of treatment studies. Several small treatment studies show promising results – but there is no treatment of choice yet.
Quality studies on patients own experiences – how they feel, see themselves, and perceive other people and the world may give us important knowledge to adapt treatment programs properly.
We are dealing with radically new diagnostic systems – the alternative model of PD in chapter III of the DSM-5 (DSM-5-AMPD) and ICD-11 with consequences for our ability to identify and assess avoidant personality pathology adequately.
Avoidant Personality Disorder from an ICD-11 Personality Disorder Perspective
Presenting author: Martin Sellbom, PhD
Co-author: Tiffany A. Brown
The ICD-11 personality disorder diagnosis has shifted to a severity dimension of no disorder, personality difficulty, mild, moderate, and severe disorder. Five optional trait qualifiers can be used to characterize the disorder (WHO, 2022). This departure from the traditional categorical constructs in DSM-5 and ICD-10 is welcome to both researchers and clinicians (Hopwood et al., 2018). However, clinicians who have familiarity with the traditional disorders could benefit from understanding how they align with the new ICD-11 PD diagnosis. In the current study, we examined DSM-5 Avoidant Personality Disorder (AvPD) in a sample of 332 community mental health patients. Of these, 27% met diagnostic criteria for AvPD based on structured clinical interview. Almost 86% of the AvPD patients would also receive at least mild ICD-11 PD. Furthermore, we compared patients with and without AvPD on clinical ratings and self-report questionnaires of the trait domain qualifiers. Patients with AvPD scores substantially higher on Negative Affectivity and Detachment than patients without AvPD across both measurement modalities. Surprisingly, there were also consistent differences on Anankastia, albeit at smaller effect sizes. Overall, these findings indicate that ICD-11 PD is likely to identify most patients traditionally diagnosed as AvPD, with prominent elevations on the Negative Affectivity and Detachment.
Avoidant personality disorder from the inside
Presenting author: Lisa Lampe, MD, PhD
Co-authors: Gin S. Malhi MD, Frankie Merritt PhD
The criteria for AVPD cover social and interpersonal fears, negative self-concept, and avoidance of social activities and interpersonal interaction. Clinical experience supports the importance of these factors, but many aspects remain speculative. We sought to answer the questions: 1) How well do participants identify with the DSM-IV criteria for AVPD? and 2) What emotions, beliefs and attitudes lead individuals with AVPD to rely on avoidance as a behavioural strategy? We also sought to test a hypothesis that rejection is experienced as a globally negative judgement of personal worth.
Twelve individuals with AVPD from clinics and the community completed a semi-structured in-depth interview. Transcribed interviews were thematically analysed, using principally an inductive and phenomenological approach, latent level analysis and interpretation. Initial coding of the data was completed by the interviewer in collaboration with another clinician. Saturation was reached after eight interviews.
Four themes were developed: 1) Connectedness: longing for relatedness but with doubt and distrust leading to distance and loneliness; 2) Authenticity: hiding the true self for fear of being rejected, then feeling inauthentic; 3) Defective self: shame, sense of inferiority, lack of importance and validity; and 4) Hypersensitivity: hypervigilance, social sensitivity with easy wounding, catastrophising and a sense of permanence of negative outcomes. The hypothesis was confirmed; additionally, it was clear that rejection would seem to confirm the individual’s own negative self-beliefs and was overall experienced as a catastrophically painful experience that might be prevented by avoidance of interaction. Avoidance behaviour was also motivated by mistrust that positive reactions of others could be genuine and by feeling different to others.
Our study has implications for diagnosis, differential diagnostics from disorders with overlapping symptoms and behaviours, and are especially relevant for treatment.
A. Avoidant personality disorder (AvPD) - diagnostic threshold and profile of personality functioning in the NorAMP study
B. Results of a systematic review on how AMPD in DSM-5 section III is able to capture AvPD according to section II
Presenting author: Ingeborg Ulltveit-Moe Eikenæs, MD, PhD
Co-authors: Tore Buer Christensen, MD, Benjamin Hummelen, PhD, MD, Muirne C. S. Paap, PhD, Sara Germans Selvik, MD, PhD, Elfrida Kvarstein, PhD, MD, Geir Pedersen, PhD, Donna S. Bender, PhD, Andrew E. Skodol, MD, Theresa Wilberg, MD, PhD and Tor Erik Nysæter, PhD
Avoidant personality disorder (AvPD) is one among six retained PDs in the Alternative Model for Personality Disorders (PDs) in DSM-5 (DSM-5 AMPD). The Level of Personality Functioning Scale (LPFS) of the AMPD aims to capture the presence and general severity of personality pathology. This scale includes four areas: Identity, Self-direction, Empathy, and Intimacy. The definition of AvPD is expanded in the AMPD, including more aspects of mentalization.
Objectives: A. Data from the Norwegian Multicenter Study of the AMPD (NorAMP) were used to examine whether moderate or greater impairment in personality functioning (level 2) was an appropriate diagnostic threshold for patients with AVPD, to what degree their mentalization problems were revealed, and the profile for AvPD of personality functioning on LPFS. B. Examine the continuity from the categorical model of PDs in section II of DSM-5 to the AMPD in section III with respect to AvPD.
Methods: A. LPFS was assessed by the Structured Clinical Interview for the DSM-5 Alternative Model for Personality Disorders Module I; (SCID-5-AMPD-I) in a heterogeneous, Norwegian sample of 282 non-psychotic patients. 42% (n=81) of the patient had AvPD. Traditional DSM-IV diagnoses were based on the Structured Clinical Interview for Axis II Disorders (SCID-II). Diagnostic efficiency statistics (Sensitivity and Specificity) were used to test diagnostic cut-off points on the LPFS. B. Systematic review included thirteen studies, calculating weighted correlation for AvPD between section II and III.
Results: A. The cut-off or threshold of level 2 was not sufficient to capture patients with AvPD, mostly due to the fact that patients with AvPD were given ratings of no or mild impairment on the Empathy area of LPFS. Data will be presented at the conference. B. Weighted correlation between global LPFS and AvPD was .39 (rw=.55 for studies of community samples and ungraduated students; rw=.17 for clinical studies). When AvPD-specific impairment of personality functioning characterizing AvPD in the AMPD was evaluated, correlations were substantially larger. The B criterion (dysfunctional traits) appeared to have incremental utility in predicting the presence of section II AvPD.
Conclusions A and B: The Empathy area of LPFS manage to catch mentalization problems in AvPD to only slight degree. We suggest further development of the interview. Meanwhile, in order to capture the severity of avoidant personality pathology more adequately, it seems advisable to use the description of the disorder specific impairments for AvPD in the AMPD.