eMedicine Specialties > Psychiatry > Adult

Avoidant Personality Disorder

Author: David C Rettew, MD, Director, Pediatric Psychiatry Clinic, Fletcher Allen Health Care; Associate Professor of Psychiatry and Pediatrics, University of Vermont College of Medicine
Coauthor(s): Michael S Jellinek, MD, President, Newton-Wellesley Hospital; Alicia C Doyle, University of Vermont College of Medicine
Contributor Information and Disclosures

Updated: Mar 4, 2008



According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), avoidant personality disorder (APD) is characterized by a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.1 Children who meet the criteria for APD are often described as being extremely shy, inhibited in new situations, and fearful of disapproval and social rejection. The degree of the symptoms and impairment is well beyond the trait of shyness that is present in as many as 40% of the population. Similar to other personality disorders, the condition becomes a major component of a person's overall character and a central theme in an individual's pattern of relating to others. Like other personality disorders, the diagnosis is rarely made in individuals younger than 18 years, even if the criteria are met. The literature regarding childhood APD is extremely limited.

More information is known about social phobia (also known as social anxiety disorder) in children, which has many overlapping features with APD.


APD is closely linked to a person's temperament. Approximately 10% of toddlers have been found to be habitually fearful and withdrawn when exposed to new people and situations. This trait appears to be stable over time. Social anxiety is hypothesized to involve the amygdala and other areas of the brain's limbic system, which, in affected individuals, is postulated to have a lower threshold of arousal and a more pronounced response when activated. Dysregulation in the brain's dopamine system has also been found to be associated with adult social anxiety disorder.


United States

The frequency of APD in children is unknown because current psychiatric practice is to avoid labeling children and adolescents with personality disorders and to describe their traits instead. However, in the adult general population, the prevalence is estimated to be 2.1–2.6%.2  Among adults receiving outpatient psychiatry treatment, the rate of APD is reported to be 14.7%.


The international frequency has not been studied in children, although a twin study of young adults found an APD rate of 1.4% in men and 2.5% in women.


  • School refusal and poor performance: As many as one third of children who refuse to go to school may have significant social anxiety.
  • Conduct problems and oppositional behavior: Many children with severe social anxiety refuse to participate in social activities and may have behavioral outbursts or panic attacks when placed in a social situation.
  • Poor peer relations: Patients with APD often have few friends and often refuse social overtures as children, behavior patterns that persist through adolescence and adulthood.
  • Lack of involvement in social and nonsocial activities: Patients with APD demonstrate lower levels of participation in athletics, extracurricular activities, and hobbies than children with depression or other personality disorders.


The frequency of APD in children of different races has not been studied.


APD is estimated to be equally common in males and females.


APD is not usually diagnosed in individuals younger than 18 years; however, most patients report an onset in childhood or adolescence, and many report continued social anxiety throughout their lives.



  • Avoidant personality disorder (APD) is a clinical diagnosis based on history provided by the child and caretakers combined with direct behavioral observation and mental status examination. According to the DSM-IV, criteria for diagnosis of APD in adults are met when a patient exhibits 4 or more of the behaviors below. No formal modification has been made for children. However, physicians should use caution when applying DSM-IV criteria, because overdiagnosis is a risk in adolescents.
    • Avoids occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection (For children, the DSM-IV reference to occupational activities can apply to school. Children with APD often have marked difficulty, especially with new classes, presentations in front of the class, and less-structured times such as recess or lunch.)
    • 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 risks or to engage in any new activities because they may prove embarrassing
  • In the Diagnostic and Statistical Manual for Primary Care, Child and Adolescent Version (DSM-PC), the diagnosis of APD is not used; however, social phobia is mentioned.
  • For patients with a suspected diagnosis of APD, evaluating for the presence of other psychiatric disorders, particularly major depression, substance abuse, and other anxiety disorders, is extremely important. The possibility that a fear of involvement with people is based on a history of child abuse and neglect should be investigated.
  • Because social anxiety disorders are often found in other family members, a family psychiatric history is beneficial. Treatment of parents and caretakers for their own psychiatric conditions may improve the outcome in the referred child.
  • Unlike milder forms of developmental shyness, children with APD or social anxiety disorder do not easily adjust to people in new situations.


  • No specific physical examination findings are associated with APD.
  • Assess the patient's hearing acuity as part of a general screening.
  • ADP may be more common in patients who have disfiguring physical conditions or limiting chronic illnesses.
  • There may be an association between APD and motor impairment in children.
  • In adults, a link has been found between APD and obesity.


  • The exact cause of APD is unknown.
  • The disorder may be related to temperamental factors that are inherited. Specifically, various anxiety disorders in childhood and adolescence have been associated with a temperament characterized by behavioral inhibition, including features of being shy, fearful, and withdrawn in new situations. Components of this temperament have been identified in infants as young as 4 months.
  • Genetic factors have been hypothesized to cause APD and social phobia because both conditions are found more frequently in certain families. A recent twin study of Norwegian young adults found a 35% genetic effect for APD; the majority (83%) of these genes are also related to other personality disorders.3
  • Environmental factors also play in role in APD. Parenting behaviors, such as low parental affection or nurturing, were associated with an elevated risk of APD when these children reached adulthood.4  
  • Retrospective studies of adults with APD report high levels of childhood emotional abuse (61%).5 However, physical abuse may be more closely linked with a diagnosis of another personality disorder or posttraumatic stress disorder (PTSD).
  • A multifactorial model of causation is likely, with genetic and environmental factors interacting from infancy in various combinations.

More on Avoidant Personality Disorder

Overview: Avoidant Personality Disorder
Differential Diagnoses & Workup: Avoidant Personality Disorder
Treatment & Medication: Avoidant Personality Disorder
Follow-up: Avoidant Personality Disorder


  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.

  2. 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. Jul 2004;65(7):948-58. [Medline].

  3. Reichborn-Kjennerud T, Czajkowski N, Neale MC, et al. Genetic and environmental influences on dimensional representations of DSM-IV cluster C personality disorders: a population-based multivariate twin study. Psychol Med. May 2007;37(5):645-53. [Medline].

  4. Johnson JG, Cohen P, Chen H, Kasen S, Brook JS. Parenting behaviors associated with risk for offspring personality disorder during adulthood. Arch Gen Psychiatry. May 2006;63(5):579-87. [Medline].

  5. Rettew DC, Zanarini MC, Yen S, et al. Childhood antecedents of avoidant personality disorder: a retrospective study. J Am Acad Child Adolesc Psychiatry. Sep 2003;42(9):1122-30. [Medline].

  6. Rettew DC. Avoidant personality disorder, generalized social phobia, and shyness: putting the personality back into personality disorders. Harv Rev Psychiatry. Dec 2000;8(6):283-97. [Medline].

  7. 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.

  8. [Best Evidence] Emmelkamp PM, Benner A, Kuipers A, et al. Comparison of brief dynamic and cognitive-behavioural therapies in avoidant personality disorder. Br J Psychiatry. Jul 2006;189:60-4. [Medline][Full Text].

  9. Skodol AE, Bender DS, Pagano ME, et al. Positive childhood experiences: resilience and recovery from personality disorder in early adulthood. J Clin Psychiatry. Jul 2007;68(7):1102-8. [Medline].

  10. Beidel DC, Turner SM. Shy Children, Phobic Adults: The Nature and Treatment of Social Phobia. Washington, DC: American Psychological Association; 1998.

  11. Kagan J. Galen's Prophecy: Temperament in Human Nature. New York, NY: Basic Books; 1994.

  12. Millon T. Modern Psychopathology: A Biosocial Approach to Maladaptive Learning and Functioning. Philadelphia, PA: WB Saunders; 1969.

  13. Schwartz CE, Snidman N, Kagan J. Adolescent social anxiety as an outcome of inhibited temperament in childhood. J Am Acad Child Adolesc Psychiatry. Aug 1999;38(8):1008-15. [Medline].

  14. 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. May 2003;160(5):952-66. [Medline].

Further Reading


avoidant personality disorder, APD, childhood APD, avoidant disorder, social phobia, social anxiety disorder, personality disorder, SSRIs, limbic system, anxiety disorder, social disorder, shy, shyness, school refusal, oppositional behavior, depression, substance abuse, child neglect, child abuse, obesity, posttraumatic stress disorder, generalized social anxiety disorder

Contributor Information and Disclosures


David C Rettew, MD, Director, Pediatric Psychiatry Clinic, Fletcher Allen Health Care; Associate Professor of Psychiatry and Pediatrics, University of Vermont College of Medicine
David C Rettew, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry and American Psychiatric Association
Disclosure: Nothing to disclose.


Michael S Jellinek, MD, President, Newton-Wellesley Hospital
Michael S Jellinek, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, and American Pediatric Society
Disclosure: Nothing to disclose.

Alicia C Doyle, University of Vermont College of Medicine
Disclosure: Nothing to disclose.

Medical Editor

Carol Diane Berkowitz, MD, Executive Vice Chair, Department of Pediatrics, Professor, Harbor-University of California at Los Angeles Medical Center
Carol Diane Berkowitz, MD is a member of the following medical societies: Alpha Omega Alpha, Ambulatory Pediatric Association, American Academy of Pediatrics, American College of Emergency Physicians, American Medical Association, American Pediatric Society, and North American Society for Pediatric and Adolescent Gynecology
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

CME Editor

Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Medical Women's Association, American Psychiatric Association, and American Society for Adolescent Psychiatry
Disclosure: Nothing to disclose.

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.


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