Although Avoidant Personality Disorder (AVPD) is associated with severe psychosocial impairment and is common in mental healthcare, it is an understudied condition. This study explored whether AVPD patients differ from patients with other Personality Disorders (PDs) in terms of general psychiatric symptoms and personality functioning. Hundred and twenty-four patients completed a test battery at admission to specialized treatment. Compared to patients with other PDs (n = 82), AVPD patients (n = 42) reported significantly higher levels of psychopathology. AVPD patients showed higher rates of maladaptive personality functioning. AVPD patients reported higher levels of general psychopathology and more signs of maladaptive personality functioning than patients with other PDs, indicating the seriousness of AVPD. These findings suggest a profile of instability, social isolation, and emotional inhibition with very weak identity integration and relational capacities for AVPD patients, although future research is needed to gain more insight in the clinical profile of AVPD.

• Avoidant Personality Disorder
• Personality Disorders
• Clinical Profile
• Personality Functioning
• Anxiety

Huhn R, Langeland W, Hoogendoorn A, Swart S, Wildschut M (2024) Profiling Psychopathology of Patients with Avoidant Personality Disor- der. JSM Anxiety Depress 5(1): 1027.

Avoidant Personality Disorder (AVPD) is characterized by a sense of personal inadequacy and strong fears of interpersonal rejection. The heightened sensitivity to criticism and expected condemnation by others lead to social detachment and isolation [1]. These symptoms are associated with severe impairments in daily life and major societal costs [2,3]. Recent studies show examples of considerable impairments in social and somatic aspects of individuals with AVPD such as being unmarried and not cohabitating, having a low level of education, low income, being unemployed, receiving disability benefits, and presence of somatic diseases [4,5]. Even compared to other Personality Disorders (PDs), AVPD seems to cause the highest level of impairment in daily functioning [4].

Furthermore, AVPD is an important clinical topic due to its prevalence in the community and within mental health care, high morbidity and high heritability. For example, a literature review of Reich and Schatzberg (2021) showed community point prevalence rates for AVPD ranging from 0.8% to 5%. Furthermore, the prevalence estimate of AVPD in psychiatric outpatients was about 14.7% [5]. In addition, family studies of heritability for AVPD ranged from 0.18 to 0.56 [6]. Moreover, the prognosis of AVPD is poor [7,8]. Though all factor analytic studies indicated a one factor solution suggesting that evaluation and treatment might be straightforward, AVPD tends to be underdiagnosed and undertreated [6]. In addition, the disorder has been neglected in research as well [6,9]. Wilberg, et al. (2023) state that there is an urgent need for studies of AVPD to increase the empirical knowledge base to develop treatments to patients’ level of severity and level of personality dysfunction.

Despite the psychosocial and societal impact of AVPD outlined above, little is still known about this specific PD. The probability of avoiding treatment by AVPD patients is found to be higher than in other groups of patients [10], which makes this group of patients hard to study. Until now, available research has mainly focused on the delineation between Social Anxiety Disorder (SAD) and AVPD [6-11]. The primary aim of the current exploratory study is to investigate whether patients with AVPD differ from patients with other PDs in terms of general psychiatric symptoms, levels of anxiety and depression, and personality functioning. To explore these possible differences we assessed a sample consisting of patients admitted to a trauma-related disorders treatment program or PD treatment program. To our knowledge, this is the first study to explore these differences in psychological profile between patients with AVPD and patients with other PDs.

Participants

This study is part of a larger study on trauma-related disorders, dissociative disorders and PDs [12,13]. Participants are patients who sought treatment at a specialized mental health care facility in the north of The Netherlands between November 2011 and March 2014. They were referred from primary care to specific treatment programs for either trauma-related disorders or PDs. Insufficient mastery of the Dutch language was the only exclusion criterion. Written informed consent was obtained after patients received an information letter and verbal explanation of the nature of the study. In total, 220 patients received an invitation to participate in the study of which 150 (77.3% women) agreed to participate in the study. There were no significant differences between respondents and non-respondents on demographic variables. For a more extensive description of the sample, we refer to [14]. A sample of 150 patients with an assumed 1:2 ratio of patients with an avoidant personality disorder versus patients with other personality disorders was sufficiently powered to detect effect sizes that we considered of interest, i.e. medium effect sizes of Cohen’s d = 0.5 or larger.

Demographic characteristics (sex, age, level of education, and employment status) were obtained using psychiatric records. To assess a PD diagnosis, we used the Structured Interview for Personality Disorders [15]. The SIDP-IV is a semi-structured interview used to measure PD diagnoses as defined in DSM-IV [16]. The SIDP-IV has good inter-rater reliability and is distinguished from other PD measures by the quality of the clinical inquiries [17]. We used the Symptom Check List Revised [18] to assess general psychiatric symptoms. The SCL-90-R is a self-report questionnaire measuring general psychopathology on a five-point Likert scale. It contains nine subscales measuring different clinical domains [18]. A global severity index (GSI) can be calculated as the mean item score of all items. Psychometric qualities of the SCL-90-R are reported as good [19].

Since AVDP is being associated with anxiety symptomatology we used the Beck Anxiety Inventory [20] to assess anxiety symptoms. The BAI is a 21-item self-report instrument that participants rate on a four-point Likert scale, for measuring the severity of anxiety symptoms in adolescents and adults during the last week. The BAI has good psychometric properties [20]. We used the Inventory of Depressive Symptoms [21] to assess depressive symptoms. The IDS is a 28-item self-report questionnaire that participants rate on a four-point Likert scale. It assesses depressive symptom severity during the last week. Psychometric properties are satisfactory [21].

Using a more dimensional approach to personality pathology, we also included two self-report measures, namely the Young Schema Questionnaire [22] and the Severity Indices of Personality Problems [23]. The SQ [22] measures character problems in a dimensional way. It is a self-report questionnaire with 205 items. The items are rated on a six-point Likert scale [24]. Young et al. [24], describe a schema as a general theme or pattern, which consists of memories, emotions, cognitions and physical experiences, related to the self and to relationships with others, which developed during childhood and expanded into adulthood. Psychometric qualities are good [22]. The SIPP- 118 [23] is a 118-item self-report questionnaire that measures 5 important domains (Self-control, Identity integration, Relational capacities, Responsibility, and Social concordance) of (mal) adaptive personality functioning. It consists of 118 items that are rated on a four-point Likert scale, covering the last 3 months. Its psychometric qualities are good [23].

Procedure

The study protocol was approved by the Institutional Review Board of Mental Health Institutions (METiGG; registration no. 11.121). After admission to one of the two treatment programs, a psychologist contacted patients. If a patient agreed to participate in the study, informed consent was obtained. Four trained and supervised psychologists administered the SIDP-IV. Some interviews were videotaped and evaluated during supervision sessions. The self-report questionnaires were handed out to fill in at home between appointments, although assistance was always offered.

First, demographic variables were summarized, using frequency counts (with percentages) or mean (with Standard Deviation [SD]). Secondly, to compare the characteristics (age, sex) of patients with AVPD with those of patients with other PDs, we computed Standardized Mean Differences (SMD’s or Cohen’s d effect sizes) and tested the differences between the two groups, using independent t-tests for interval and chi- squares for dichotomous variables. Cohen’s d effect size values of 0.2, 0.5 and 0.8 were interpreted as a small, medium and large effect size, respectively. Differences in severity scores on the SCL-90-R (both the total score and the anxiety subscale score), IDS, BAI, SQ subscale scores, and SIPP-118 subscale scores between the group patients with AVPD and patients with other PDs were also translated into Cohen’s d effect sizes and tested using an independent samples t-test. We chose the Welch’s Test for Unequal Variances because it is seen as robust with respect to type I errors [25]. To correct for multiple testing we chose a liberal two-sided alpha level of 0.01. Inter-rater agreement for the interview was high (93%). Internal consistency as measured by Cronbach’s alpha for self-report questionnaires was also high (ranging from .76 to .83). We had no missing data.

From our sample of 150 participants, we selected all participants who met criteria for one or more PDs (n =124) as measured using the SIDP-IV. Of these 124 patients with one or more PDs 42 patients met criteria of an AVPD (with or without a comorbid PD). The group of patients with other PDs consisted of Paranoid PD (n = 9), Schizotypical PD (n = 3), Antisocial PD (n= 1), Borderline PD (n = 44), Dependent PD (n = 12), Obsessive Compulsive PD (n = 20), and PD not otherwise specified (n = 90). Due to comorbidity, the total number exceeds 124. In the AVPD group 71% of patients were female, compared to 78% in the other PD group (d = -0.2, p = .437). Mean age in the AVPD group was 32 years, compared to 34 years in the other PD group (M= 31.5, SD = 11.7, and M = 34.0, SD = 11.8, d = -0.2, p = .419). In the AVPD group 5% was educated at the primary school level, 9% was educated at the level of lower vocational education, 56% was educated at the level of secondary vocational education, 16% was educated at the level of senior general secondary education, 2% was educated at the level of pre-university education, and 12% was educated at the level of higher vocational education. For the other PD group these percentages were respectively 12% (primary school level), 21% (lower vocational education), 37% (secondary vocational education), 15% (senior general secondary education), 2% (pre-university education), 13% (higher vocational education) (p = .269). None of the participants attended university. In both groups, 21% of patients was currently employed (d = 0.0, p = .928). No statistically significant differences between the AVPD versus other PD group were found regarding sex, age, educational level, and employment status, and only small effect sizes were found.

Mean scores and standard deviations on the self-report questionnaires are displayed in Table 1.

Table 1: Means and Standard Deviations of Scores on Measures.

Compared to patients with other PDs, AVPD patients showed a medium effect size and statistically significantly higher levels of general psychopathology (p = .009) measured with the SCL-90-R. At a more dimensional level, patients with AVPD showed lower rates on the domains of identity integration (d = -0.7, p <.001) and relational capacities (d= -0.5, p = .009), indicating higher rates of maladaptive personality functioning according to the SIPP-18. Compared to patients with other PDs, patients with AVPD showed a statistically significantly higher rate on the total score of the SQ (d = 0.6, p = .002), and on the subscales abandonment/ instability (d = 0.5, p = .005), social isolation/ alienation (d = 0.6, p < .001), social undesirability (d = 0.9, p < .001), dependence/ incompetence (d = 0.8, p < .001), failure to achieve (d = 0.7, p < .001), subjugation (d = 0.5, p = .005), and emotional inhibition (d = 0.6, p = .002), also indicating higher rates of maladaptive personality functioning. Regarding the level of anxiety symptoms (measured with the BAI and anxiety subscale of SCL-90-R) and depressive symptoms (measured with the IDS) no statistically significant differences between the two groups were found.

To our knowledge, this is the first study to explore possible differences between patients with AVPD and patients with other PDs in terms of general psychiatric symptoms, levels of anxiety and depression, and personality pathology/functioning. The current naturalistic study indicates that patients with AVPD report higher levels of general psychopathology and show more signs of maladaptive personality functioning than patients with other PDs. These findings give an impression of the serious impairments that patients with AVPD have to deal with. Given our findings of higher levels of general psychopathology and more signs of maladaptive personality functioning in AVPD patients compared to patients with other PDs, the fact that this patient group is understudied is even more concerning.

We found that there is no difference in level of anxiety between patients with AVPD and patients with other PDs. A possible explanation is that anxiety, although originally associated with the former DSM-IV cluster C (avoidant, dependent and obsessive- compulsive) PDs, is also associated with other PDs. For example, Zanarini et al. [24], reported twice as much anxiety symptoms in patients with Borderline PD than in patients with other PDs. Moreover, most research into AVPD has focused on the delineation between AVPD and SAD [6]. Based on our findings, it seems that focusing mainly on anxiety may result in missing an important part of the core symptomatology. Our findings suggest that the major problems with AVPD seem to center more on lack of sociability than anxiety. The psychological profile of AVPD seems to be a profile of instability, social isolation, and emotional inhibition with very weak identity integration and relational capacities. This is in line with findings of Pellecchia et al. [27], who found that as far as the interpersonal functioning is concerned, the lack of sociability was more severe in the AVPD group compared with a SAD group. Their results suggest that specific impairments in critical areas of self-domains and interpersonal domains of personality functioning may serve as markers distinguishing AVPD from SAD. Our findings as well as those reported by Pellecchia et al. [27], are in line with the DSM-5 alternative model of personality disorders regarding disfunction of the self and relationships [28].

A strength of our study is that we used a structured clinical interview by trained psychologists to measure a clinical diagnosis of a PD, considering all PD’s, ensuring a high level of diagnostic validity. Furthermore, we were able to conduct our research in a naturalistic setting, consisting of patients seeking help in a specialized mental health care facility, which gave us the opportunity to study a group of patients with higher symptom severity and more limited socio-occupational functioning than usually seen in patients in primary care and finally, we were able to include a substantial amount of patients with AVPD.

Some limitations of our study should also be mentioned. First, there is the issue of multiple testing. Although we used an adapted threshold of α = .01, this level may be too liberal given the large number of tests performed. However, the differences that were indicated as statistically significant using the liberal threshold corresponded to effect sizes that were medium to large, and therefore of clinical interest, and may be confirmed in future research. Secondly, our data were collected between 2011 and 2014, before DSM-5, so we used the DSM-IV (SIDP- IV) instead of the DSM-5 to establish PD status. However, since differences between DSM-IV and DSM-5 in classifying PD are rather limited, we do not expect much difference in outcome if we had had the opportunity to use DSM-5. Thirdly, we did not use a specific instrument to measure social anxiety, as for example the Liebowitz social anxiety scale [29], however the BAI is widely used to measure anxiety levels. Furthermore, findings based on the BAI led to the same conclusion as those based on the anxiety subscale of the SCL-90-R. Fourthly, our AVPD group consists of patients with an AVPD and comorbid PD’s instead of patients with an AVPD only (and no other PD’s). Since we had 4 patients in our sample with an AVPD and no other PD’s we were not able to study this group. The other PD group consists of patients without an AVPD. Although this is a serious limitation to our results we do believe that it reflects the reality that in a naturalistic group of patients seeking help in a specialized mental health care facility comorbidity is the rule rather than the exception.

In conclusion, we found that patients with AVPD report higher levels of general psychopathology and more signs of maladaptive personality functioning than patients with other PDs. Since PD patients are known to be quite impaired in general functioning our findings underline the seriousness of AVPD when it comes to general psychopathology and personality functioning. Looking at the psychological profile of AVPD, we found that the major problems with AVPD seem to center more on a lack of sociability than anxiety. Future research is needed to gain more insight in the clinical profile of AVPD, ultimately leading to more specific research on the best way to treat this debilitating disorder.

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