DSM-III

Diagnostic Criteria

The following are characteristic of the individual's current and long-term functioning, are not limited to episodes of illness, and cause either significant impairment in social or occupational functioning or subjective distress.

A. Hypersensitivity to rejection, e.g., apprehensively alert to signs of social derogation, interprets innocuous events as ridicule.

B. Unwillingness to enter into relationships unless given unusually strong guarantees of uncritical acceptance.

C. Social withdrawal, e.g., distance self from close personal attachments, engages in peripheral social and vocational roles.

D. Desire for affection and acceptance.

E. Low self-esteem, e.g., devalues self-achievements and is overly dismayed by personal shortcomings.

F. If under 18, does not meet the criteria for Avoidant Disorder of Childhood or Adolescence.

Differential Diagnosis

Schizoid Personality Disorder

In Schizoid Personality Disorder there is also social isolation, but without a desire for social involvement and with an indifference to criticism.

Social Phobias

In Social Phobias humiliation is a concern, but a specific situation, such as public speaking, is avoided rather than personal relationships. However, these disorders may coexist.

Avoidant Disorder of Childhood or Adolescence

In Avoidant Disorder of Childhood or Adolescence there is a similar clinical picture and this diagnosis preempts the diagnosis of Avoidant Personality Disorder if the individual is under 18.

DSM-IV

Diagnostic Criteria

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

  1. avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection
  2. is unwilling to get involved with people unless certain of being liked
  3. shows restraint within intimate relationships because of the fear of being shamed or ridiculed
  4. is preoccupied with being criticized or rejected in social situations
  5. is inhibited in new interpersonal situations because of feelings of inadequacy
  6. views self as socially inept, personally unappealing, or inferior to others
  7. is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing

Differential Diagnosis

Social Phobia and Panic Disorder With Agoraphobia

There appears to be a great deal of overlap between Avoidant Personality Disorder and Social Phobia, Generalized Type, so much so that they may be alternative conceptualizations of the same or similar conditions. Avoidance also characterizes both Avoidant Personality Disorder and Panic Disorder With Agoraphobia, and they often co-occur. The avoidance in Panic Disorder With Agoraphobia typically starts after the onset of Panic Attacks and may vary based on their frequency and intensity. In contrast, the avoidance in Avoidant Personality Disorder tends to have an early onset, an absence of clear precipitations, and a stable course.

Other Personality Disorders

Other Personality Disorders may be confused with Avoidant Personality Disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more Personality Disorders in addition to Avoidant Personality Disorder, all can be diagnosed.

Dependent Personality Disorder

Both Avoidant Personality Disorder and Dependent Personality Disorder are characterized by feelings of inadequacy, hypersensitiity to criticism, and a need for reassurance. Although the primary focus of concern in Avoidant Personality Disorder is avoidance of humiliation and rejection, in Dependent Personality Disorder the focus is on being taken care of. However, Avoidant Personality Disorder and Dependent Personality Disorder are particularly likely to co-occur.

Schizoid and Schizotypal Personality Disorders

Like Avoidant Personality Disorder, Schizoid Personality Disorder and Schizotypal Personality Disorder are characterized by social isolation. However, individuals with Avoidant Personality Disorder want to have relationships with others and feel their loneliness deeply, whereas those with Schizoid or Schizotypal Personality Disorder may be content with and even prefer their social isolation.

Paranoid Personality Disorder

Paranoid Personality Disorder and Avoidant Personality Disorder are both characterized by a reluctance to confide in others. However, in Avoidant Personality Disorder, this reluctance is due more to a fear of being embarrassed or being found inadequate than to a fear of others' malicious intent.

Personality Change Due to a General Medical Condition and symptoms related to substance use

Avoidant Personality Disorder must be distinguished from Personality Change Due to a General Medical Condition, in which the traits emerge due to the direct effects of a general medical condition on the central nervous system. It must also be distinguished from symptoms that may develop in association with chronic substance use (e.g., Cocaine-Related Disorder Not Otherwise Specified).

Normal personality traits

Many individuals display avoidant personality traits. Only when these traits are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress do they constitute Avoidant Personality Disorder.

 DSM-5

Diagnostic Criteria

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

  1. Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection.
  2. Is unwilling to get involved with people unless certain of being liked.
  3. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.
  4. Is preoccupied with being criticized or rejected in social situations.
  5. Is inhibited in new interpersonal situations because of feelings of inadequacy.
  6. Views self as socially inept, personally unappealing, or inferior to others.
  7. Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.

Alternative Model

Proposed Diagnostic Criteria

A. Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas:

  1. Identity: Low self-esteem associated with self-appraisal as socially inept, personally unappealing, or inferior; excessive feelings of shame.
  2. Self-direction: Unrealistic standards for behavior associated with reluctance to pursue goals, take personal risks, or engage in new activities involving interpersonal contact.
  3. Empathy: Preoccupation with, and sensitivity to, criticism or rejection, associated with distorted inference of others' perspectives as negative.
  4. Intimacy: Reluctance to get involved with people unless being certain of being liked; diminished mutuality within intimate relationships because of fear of being shamed or ridiculed.

B. Three or more of the following four pathological personality traits, one of which must be (1) Anxiousness:

  1. Anxiousness (an aspect of Negative Affectivity): Intense feelings of nervousness, tenseness, or panic, often in reaction to social situations; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of embarrassment.
  2. Withdrawal (an aspect of Detachment): Reticence in social situations; avoidance of social contacts and activity; lack of initiation of social contact.
  3. Anhedonia (an aspect of Detachment): Lack of enjoyment from, engagement in, or energy for life's experiences; deficits in the capacity to feel pleasure or take interest in things.
  4. Intimacy avoidance (an aspect of Detachment): Avoidance of close or romantic relationships, interpersonal attachments, and intimate sexual relationships.

C. The impairments in personality functioning and the individual's personality trait expression are relatively inflexible and pervasive across a broad range of personal and social situations.

D. The impairments in personality functioning and the individual's personality trait expression are relatively stable across time, with onsets that can be traced back to at least adolescence or early adulthood.

E. The impairments in personality functioning and the individual's personality trait expression are not better explained by another mental disorder.

F. The impairments in personality functioning and the individual's personality trait expression are not solely attributable to the physiological effects of a substance or another medical condition (e.g., severe head trauma).

G. The impairments in personality functioning and the individual's personality trait expression are not better understood as normal for an individual's developmental stage or sociocultural environment.

Specifiers

Considerably heterogeneity in the form of additional personality traits is found among individuals diagnosed with avoidant personality disorder. Trait and level of personality functioning specifiers can be used to record additional personality features that may be present in avoidant personality disorder. For example, other Negative Affectivity traits (e.g., depressivity, separation insecurity, submissiveness, suspiciousness, hostility) are not diagnostic criteria for avoidant personality disorder (see Criterion B) but can be specified when appropriate. Furthermore, although moderate or greater impairment in personality functioning is required for the diagnosis of avoidant personality disorder (Criterion A), the level of personality functioning also can be specified.

Differential Diagnosis

Anxiety disorders

There appears to be a great deal of overlap between avoidant personality disorder and social anxiety disorder (social phobia), so much so that they may be alternative conceptualizations of the same or similar conditions. Avoidance also characterizes both avoidant personality disorder and agoraphobia, and they often co-occur.

Other personality disorders

Other personality disorders may be confused with avoidant personality disorder because they have certain features in common. It is, therefore, important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more personality disorders in addition to avoidant personality disorder, all can be diagnosed.

Dependent personality disorder

Both avoidant personality disorder and dependent personality disorder are characterized by feelings of inadequacy, hypersensitivity to criticism, and a need for reassurance. Although the primary focus of concern in avoidant personality disorder is avoidance of humiliation and rejection, in dependent personality disorder the focus is on being taken care of. However, avoidant personality disorder and dependent personality disorder are particularly likely to co-occur.

Schizoid and schizotypal personality disorder

Like avoidant personality disorder, schizoid personality disorder and schizotypal personality disorder are characterized by social isolation. However, individuals with avoidant personality disorder want to have relationships with others and feel their loneliness deeply, whereas those with schizoid or schizotypal personality disorder may be content with and even prefer their social isolation.

Paranoid personality disorder

Paranoid personality disorder and avoidant personality disorder are both characterized by a reluctance to confide in others. However, in avoidant personality disorder, this reluctance is attributable more to a fear of being embarrassed or being found inadequate than to a fear of others' malicious intent.

Other personality traits

Many individuals display avoidant personality traits. Only when these traits are inflexible, maladaptive, and persisting and cause significant functional impairment or subjective distress do they constitute avoidant personality disorder.

Personality change due to another medical condition

Avoidant personality disorder must be distinguished from personality change due to another medical condition, in which the traits that emerge are attributable to the effects of another medical condition on the central nervous system.

Substance use disorders

Avoidant personality disorder must also be distinguished from symptoms that may develop in association with persistent substance use.

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