How is Avoidant Personality Disorder Treated?

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Medical Care: Avoidant personality disorder 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 rule out comorbid 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. Physicians, however, should bear in mind that parents of children with APD also often have personal social difficulties; these have the potential to create treatment obstacles.

Medications

No medications have been specifically tested or FDA approved for children and adolescents with avoidant personality disorder. 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 evidence exists in the literature regarding adult APD for the effectiveness of benzodiazepines, monamine oxidase inhibitors (MAOIs), and the anticonvulsant gabapentin in the treatment of social anxiety.

Drug Category: Selective serotonin reuptake inhibitors -- 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 Food and Drug Administration (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.

(Note: In 2005, the FDA ordered the manufacturers of all antidepressants to include in their labeling a warning that recommends close observation of both adult and pediatric patients who are being treated with these medications. Antidepressants have been linked to suicidality (both thoughts and actions) in pediatric patients (age 18 and under). Prozac is the only antidepressant specifically approved by the FDA for treating children and adolescents with depression.)

Drug Category: Benzodiazepines -- Bind to a specific benzodiazepine receptor on GABA receptor complex, thereby increasing GABA affinity for its receptor. 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.

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. 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 avoidant personality disorder 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.
• 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.

Special Concerns:

• Differentiation between avoidant personality disorder 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 (in comparison to children with autism-spectrum disorders)
  • Desire for closeness that is impeded by anxiety (compared to children with schizoid personality disorder or children who prefer to be alone or 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 exist. 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:

• American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association 1994.
• Beidel DC, Turner SM: Shy Children, Phobic Adults: The Nature and Treatment of Social Phobia. Washington, DC: American Psychological Association 1998.
• 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 2004 Jul; 65(7): 948-58[Medline].
• Kagan J: Galen's Prophecy: Temperament in Human Nature. New York, NY: Basic Books 1994.
• Lieb R, Wittchen HU, Hofler M, et al: Parental psychopathology, parenting styles, and the risk of social phobia in offspring: a prospective-longitudinal community study. Arch Gen Psychiatry 2000 Sep; 57(9): 859-66[Medline].
• 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.
• Millon T: Modern Psychopathology: A Biosocial Approach to Maladaptive Learning and Functioning. Philadelphia, Pa: WB Saunders 1969.
• Rettew DC: Avoidant personality disorder, generalized social phobia, and shyness: putting the personality back into personality disorders. Harv Rev Psychiatry 2000 Dec; 8(6): 283-97[Medline].
• Rettew DC, Zanarini MC, Yen S, et al: Childhood antecedents of avoidant personality disorder: a retrospective study. J Am Acad Child Adolesc Psychiatry 2003 Sep; 42(9): 1122-30[Medline].
• Schwartz CE, Snidman N, Kagan J: Adolescent social anxiety as an outcome of inhibited temperament in childhood. J Am Acad Child Adolesc Psychiatry 1999 Aug; 38(8): 1008-15[Medline].
• 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 2003 May; 160(5): 952-66[Medline].

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Reviewed: 04/2006