Avoidant Personality Disorder: a Current Review

  • Anna Weinbrecht
  • Lars Schulze
  • Johanna Boettcher
  • Babette Renneberg
Personality Disorders (C Schmahl, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Personality Disorders


This review focuses on recent research on diagnostic aspects, etiology, and treatment of avoidant personality disorder (AVPD). Current studies stress the close relation between AVPD and social anxiety disorder, the influence of genetic factors in the development of AVPD, and the relative stability of symptoms. Treatment approaches should target the pervasive patterns of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. Empirical evidence for cognitive-behavior and schema therapy is promising. Few other therapeutic approaches have been developed, but until now, these have only been investigated in case studies. We conclude that AVPD qualifies as a neglected disorder and that more research specifically on avoidant personality disorder symptoms and its treatment is needed.


Avoidant personality disorder Diagnostic Etiology Psychotherapy 


Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no competing interests.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Cramer V, Torgersen S, Kringlen E. Personality disorders and quality of life. A population study. Compr Psychiatry. 2006;47(3):178–84.CrossRefPubMedGoogle Scholar
  2. 2.
    Ullrich S, Farrington DP, Coid JW. Dimensions of DSM-IV personality disorders and life-success. J Pers Disord. 2007;21(6):657–63.CrossRefPubMedGoogle Scholar
  3. 3.
    Olsson I, Dahl AA. Avoidant personality problems—their association with somatic and mental health, lifestyle, and social network. A community-based study. Compr Psychiatry. 2012;53(6):813–21.CrossRefPubMedGoogle Scholar
  4. 4.
    Crawford TN, Cohen P, Johnson JG, Kasen S, First MB, Gordon K, et al. Self-reported personality disorder in the children in the community sample: convergent and prospective validity in late adolescence and adulthood. J Pers Disord. 2005;19(1):30–52.CrossRefPubMedGoogle Scholar
  5. 5.
    Grant BF, Hasin DS, Stinson FS, Dawson DA, Chou SP, Ruan WJ, 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;65(7):948–58.CrossRefPubMedGoogle Scholar
  6. 6.
    Torgersen S. The nature (and nurture) of personality disorders. Scand J Psychol. 2009;50(6):624–32.CrossRefPubMedGoogle Scholar
  7. 7.
    Zimmerman M, Rothschild L, Chelminski I. The prevalence of DSM-IV personality disorders in psychiatric outpatients. Am J Psychiatry. 2005;162(10):1911–8.CrossRefPubMedGoogle Scholar
  8. 8.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: Author; 2013.Google Scholar
  9. 9.
    Cox BJ, Pagura J, Stein MB, Sareen J. The relationship between generalized social phobia and avoidant personality disorder in a national mental health survey. Depress Anxiety. 2009;26(4):354–62.CrossRefPubMedGoogle Scholar
  10. 10.
    Hofmann SG, Newman MG, Ehlers A, Roth WT. Psychophysiological differences between subgroups of social phobia. J Abnorm Psychol. 1995;104(1):224–31.CrossRefPubMedGoogle Scholar
  11. 11.
    Herbert JD, Hope DA, Bellack AS. Validity of the distinction between generalized social phobia and avoidant personality disorder. J Abnorm Psychol. 1992;101(2):332–9.CrossRefPubMedGoogle Scholar
  12. 12.
    Friborg O, Martinussen M, Kaiser S, Overgard KT, Rosenvinge JH. Comorbidity of personality disorders in anxiety disorders: a meta-analysis of 30 years of research. J Affect Disord. 2013;145(2):143–55.CrossRefPubMedGoogle Scholar
  13. 13.
    Alden LE, Laposa JM, Taylor CT, Ryder AG. Avoidant personality disorder: current status and future directions. J Pers Disord. 2002;16(1):1–29.CrossRefPubMedGoogle Scholar
  14. 14.
    Bogels SM, Alden L, Beidel DC, Clark LA, Pine DS, Stein MB, et al. Social anxiety disorder: questions and answers for the DSM-V. Depress Anxiety. 2010;27(2):168–89.CrossRefPubMedGoogle Scholar
  15. 15.
    Reich J. Chapter 2—avoidant personality disorder and its relationship to social anxiety disorder. In: Hofmann SG, DiBartolo PM, editors. Social anxiety. 3rd ed. San Diego: Academic; 2014. p. 27–44.Google Scholar
  16. 16.
    Marques L, Porter E, Keshaviah A, Pollack MH, Van Ameringen M, Stein MB, et al. Avoidant personality disorder in individuals with generalized social anxiety disorder: what does it add? J Anxiety Disord. 2012;26(6):665–72.PubMedCentralCrossRefPubMedGoogle Scholar
  17. 17.
    Eikenaes I, Hummelen B, Abrahamsen G, Andrea H, Wilberg T. Personality functioning in patients with avoidant personality disorder and social phobia. J Pers Disord. 2013;27(6):746–63.CrossRefPubMedGoogle Scholar
  18. 18.
    Rettew DC. Avoidant personality disorder, generalized social phobia, and shyness: putting the personality back into personality disorders. Harv Rev Psychiatry. 2000;8(6):283–97.CrossRefPubMedGoogle Scholar
  19. 19.
    Sanislow CA, Bartolini EE, Zoloth EC. Avoidant personality disorder. In: Ramachandran VS, editor. Encyclopedia of human behavior. 2nd ed. San Diego: Academic; 2012. p. 257–66.CrossRefGoogle Scholar
  20. 20.
    Skodol AE, Bender DS, Morey LC, Clark LA, Oldham JM, Alarcon RD, et al. Personality disorder types proposed for DSM-5. J Pers Disord. 2011;25(2):136–69.CrossRefPubMedGoogle Scholar
  21. 21.
    Stuart S, Pfohl B, Battaglia M, Bellodi L, Grove W, Cadoret R. The cooccurrence of DSM-III-R personality disorders. J Pers Disord. 1998;12(4):302–15.CrossRefPubMedGoogle Scholar
  22. 22.
    Bachrach N, Croon MA, Bekker MH. Factor structure of self-reported clinical disorders and personality disorders: a review of the existing literature and a factor analytical study. J Clin Psychol. 2012;68(6):645–60.CrossRefPubMedGoogle Scholar
  23. 23.
    Caspi A, Houts RM, Belsky DW, Goldman-Mellor SJ, Harrington H, Israel S, et al. The p factor: one general psychopathology factor in the structure of psychiatric disorders? Clin Psychol Sci. 2014;2(2):119–37.PubMedCentralCrossRefPubMedGoogle Scholar
  24. 24.••
    Wright AG, Pincus AL, Lenzenweger MF. A parallel process growth model of avoidant personality disorder symptoms and personality traits. Personal Disord. 2013;4(3):230–8. In this longitudinal study, the rates of change in avoidant personality disorder symptoms were associated to rates of change in normal personality traits (interpersonal dominance, affiliation, and neuroticism). This supports the proposition that personality disorders can be conceptualized as expressions of normal personality traits and stresses the crucial role of neuroticism for avoidant personality disorder. PubMedCentralCrossRefPubMedGoogle Scholar
  25. 25.
    Lenzenweger MF. Stability and change in personality disorder features: the Longitudinal Study of Personality Disorders. Arch Gen Psychiatry. 1999;56(11):1009–15.CrossRefPubMedGoogle Scholar
  26. 26.
    Grilo CM, Sanislow CA, Gunderson JG, Pagano ME, Yen S, Zanarini MC, et al. Two-year stability and change of schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders. J Consult Clin Psychol. 2004;72(5):767–75.PubMedCentralCrossRefPubMedGoogle Scholar
  27. 27.
    Johnson JG, Cohen P, Kasen S, Skodol AE, Hamagami F, Brook JS. Age-related change in personality disorder trait levels between early adolescence and adulthood: a community-based longitudinal investigation. Acta Psychiatr Scand. 2000;102(4):265–75.CrossRefPubMedGoogle Scholar
  28. 28.
    Sanislow CA, Little TD, Ansell EB, Grilo CM, Daversa M, Markowitz JC, et al. Ten-year stability and latent structure of the DSM-IV schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders. J Abnorm Psychol. 2009;118(3):507–19.CrossRefPubMedGoogle Scholar
  29. 29.••
    Hallquist MN, Lenzenweger MF. Identifying latent trajectories of personality disorder symptom change: growth mixture modeling in the longitudinal study of personality disorders. J Abnorm Psychol. 2013;122(1):138–55. In this longitudinal study, latent trajectories of personality dysfunction were investigated. Results indicated that avoidant personality disorder can develop at a later stage of life and that this is associated with lower positive emotionality. PubMedCentralCrossRefPubMedGoogle Scholar
  30. 30.•
    Gjerde LC, Czajkowski N, Roysamb E, Ystrom E, Tambs K, Aggen SH et al. A longitudinal, population-based twin study of avoidant and obsessive-compulsive personality disorder traits from early to middle adulthood. Psychol Med. 2015:1–10. This longitudinal twin study provided support that genetic factors contribute more to the phenotypic stability of avoidant personality disorder than environmental factors. Google Scholar
  31. 31.••
    Hopwood CJ, Morey LC, Donnellan MB, Samuel DB, Grilo CM, McGlashan TH, et al. Ten-year rank-order stability of personality traits and disorders in a clinical sample. J Pers. 2013;81(3):335–44. This study assessed 10-year stability of personality traits and personality disorder dimensions in a clinical sample. Stability was relatively greater for traits than personality disorders. PubMedCentralCrossRefPubMedGoogle Scholar
  32. 32.
    Gjerde LC, Czajkowski N, Roysamb E, Orstavik RE, Knudsen GP, Ostby K, et al. The heritability of avoidant and dependent personality disorder assessed by personal interview and questionnaire. Acta Psychiatr Scand. 2012;126(6):448–57.PubMedCentralCrossRefPubMedGoogle Scholar
  33. 33.
    Isomura K, Boman M, Ruck C, Serlachius E, Larsson H, Lichtenstein P, et al. Population-based, multi-generational family clustering study of social anxiety disorder and avoidant personality disorder. Psychol Med. 2015;45(8):1581–9.CrossRefPubMedGoogle Scholar
  34. 34.
    Joyce PR, McKenzie JM, Luty SE, Mulder RT, Carter JD, Sullivan PF, et al. Temperament, childhood environment and psychopathology as risk factors for avoidant and borderline personality disorders. Aust N Z J Psychiatry. 2003;37(6):756–64.PubMedGoogle Scholar
  35. 35.
    Meyer B, Carver CS. Negative childhood accounts, sensitivity, and pessimism: a study of avoidant personality disorder features in college students. J Pers Disord. 2000;14(3):233–48.CrossRefPubMedGoogle Scholar
  36. 36.
    Eikenaes I, Egeland J, Hummelen B, Wilberg T. Avoidant personality disorder versus social phobia: the significance of childhood neglect. PLoS One. 2015;10(3), e0122846.PubMedCentralCrossRefPubMedGoogle Scholar
  37. 37.
    Carr SN, Francis AJ. Early maladaptive schemas and personality disorder symptoms: an examination in a non-clinical sample. Psychol Psychother. 2010;83(4):333–49.CrossRefPubMedGoogle Scholar
  38. 38.
    Renneberg B, Goldstein AJ, Phillips D, Chambless DL. Intensive behavioral group treatment of avoidant personality-disorder. Behav Ther. 1990;21(3):363–77.CrossRefGoogle Scholar
  39. 39.
    Alden L. Short-term structured treatment for avoidant personality-disorder. J Consult Clin Psychol. 1989;57(6):756–64.CrossRefPubMedGoogle Scholar
  40. 40.
    Stravynski A, Belisle M, Marcouiller M, Lavallee YJ, Elie R. The treatment of avoidant personality disorder by social skills training in the clinic or in real-life settings. Can J Psychiatry. 1994;39(8):377–83.PubMedGoogle Scholar
  41. 41.
    Beck AT, Freeman AM. Cognitive therapy of personality disorders. New York, NY, US: Guilford Press; 1990.Google Scholar
  42. 42.
    Clark DM, Wells A. A cognitive model of social phobia. In: Heimberg RG, Liebowitz MR, Hope DA, Schneier FR, editors. Social phobia: diagnosis, assessment and treatment. New York: Guildford Press; 1995. p. 66–93.Google Scholar
  43. 43.
    Emmelkamp PM, Benner A, Kuipers A, Feiertag GA, Koster HC, van Apeldoorn FJ. Comparison of brief dynamic and cognitive-behavioural therapies in avoidant personality disorder. Br J Psychiatry. 2006;189:60–4.CrossRefPubMedGoogle Scholar
  44. 44.
    Rees CS, Pritchard R. Brief cognitive therapy for avoidant personality disorder. Psychotherapy (Chic). 2015;52(1):45–55.CrossRefGoogle Scholar
  45. 45.
    Strauss JL, Hayes AM, Johnson SL, Newman CF, Brown GK, Barber JP, et al. Early alliance, alliance ruptures, and symptom change in a nonrandomized trial of cognitive therapy for avoidant and obsessive-compulsive personality disorders. J Consult Clin Psychol. 2006;74(2):337–45.PubMedCentralCrossRefPubMedGoogle Scholar
  46. 46.
    Borge FM, Hoffart A, Sexton H, Clark DM, Markowitz JC, McManus F. Residential cognitive therapy versus residential interpersonal therapy for social phobia: a randomized clinical trial. J Anxiety Disord. 2008;22(6):991–1010.CrossRefPubMedGoogle Scholar
  47. 47.
    Abbass A, Sheldon A, Gyra J, Kalpin A. Intensive short-term dynamic psychotherapy for DSM-IV personality disorders: a randomized controlled trial. J Nerv Ment Dis. 2008;196(3):211–6.CrossRefPubMedGoogle Scholar
  48. 48.
    Barber JP, Morse JQ, Krakauer ID, Chittams J, Crits-Christoph K. Change in obsessive-compulsive and avoidant personality disorders following time-limited supportive-expressive therapy. Psychotherapy (Chic). 1997;34(2):133–43.CrossRefGoogle Scholar
  49. 49.
    Svartberg M, Stiles TC, Seltzer MH. Randomized, controlled trial of the effectiveness of short-term dynamic psychotherapy and cognitive therapy for cluster C personality disorders. Am J Psychiatry. 2004;161(5):810–7.CrossRefPubMedGoogle Scholar
  50. 50.
    Leichsenring F, Salzer S. A unified protocol for the transdiagnostic psychodynamic treatment of anxiety disorders: an evidence-based approach. Psychotherapy (Chic). 2014;51(2):224–45.CrossRefGoogle Scholar
  51. 51.
    Luborsky L, Mark D. Short-term supportive-expressive psychoanalytic psychotherapy. In: Crits-Christoph P, Barber JP, Crits-Christoph P, Barber JP, editors. Handbook of short-term dynamic psychotherapy. New York, NY, US: Basic Books; 1991. p. 110–36.Google Scholar
  52. 52.
    Young JE, Klosko JS, Weishaar ME. Schema therapy: a practitioner’s guide. New York, NY, US: Guilford Press; 2003.Google Scholar
  53. 53.
    Arntz A. Schematherapie für Cluster-C-Persönlichkeitsstörungen. Z Psychiatr Psychol Psychother. 2011;59(3):195–204.Google Scholar
  54. 54.
    Weertman A, Arntz A. Effectiveness of treatment of childhood memories in cognitive therapy for personality disorders: a controlled study contrasting methods focusing on the present and methods focusing on childhood memories. Behav Res Ther. 2007;45(9):2133–43.CrossRefPubMedGoogle Scholar
  55. 55.••
    Bamelis LL, Evers SM, Spinhoven P, Arntz A. Results of a multicenter randomized controlled trial of the clinical effectiveness of schema therapy for personality disorders. Am J Psychiatry. 2014;171(3):305–22. This study demonstrated that a greater proportion of patients with Cluster C personality disorder treated with schema therapy recovered in comparison to clarification-oriented psychotherapy and treatment as usual. CrossRefPubMedGoogle Scholar
  56. 56.
    Skewes SA, Samson RA, Simpson SG, van Vreeswijk M. Short-term group schema therapy for mixed personality disorders: a pilot study. Front Psychol. 2014;5:1592.PubMedCentralPubMedGoogle Scholar
  57. 57.
    Group schema therapy versus group cognitive behavioral therapy for social anxiety disorder with comorbid avoidant personality disorder [database on the Internet]. in [Internet]. NTR number: NTR3921. 2013. Available from: Available online at: Accessed:
  58. 58.
    Dimaggio G, D’Urzo M, Pasinetti M, Salvatore G, Lysaker PH, Catania D, et al. Metacognitive interpersonal therapy for co-occurrent avoidant personality disorder and substance abuse. J Clin Psychol. 2015;71(2):157–66.CrossRefPubMedGoogle Scholar
  59. 59.
    Pos AE. Emotion focused therapy for avoidant personality disorder: pragmatic considerations for working with experientially avoidant clients. J Contemp Psychother. 2014;44(2):127–39.CrossRefGoogle Scholar
  60. 60.
    Chan CC, Bach PA, Bedwell JS. An integrative approach using third-generation cognitive-behavioral therapies for avoidant personality disorder. Clinical Case Studies. 2015;1–16.Google Scholar
  61. 61.
    Gilbert SE, Gordon KC. Interpersonal psychotherapy informed treatment for avoidant personality disorder with subsequent depression. Clinical Case Studies. 2012;12(2):111–2.CrossRefGoogle Scholar
  62. 62.
    Brown EJ, Heimberg RG, Juster HR. Social phobia subtype and avoidant personality-disorder—effect on severity of social phobia, impairment, and outcome of cognitive-behavioral treatment. Behav Ther. 1995;26(3):467–86.CrossRefGoogle Scholar
  63. 63.
    Feske U, Perry KJ, Chambless DL, Renneberg B, Goldstein AJ. Avoidant personality disorder as a predictor for treatment outcome among generalized social phobics. J Pers Disord. 1996;10(2):174–84.CrossRefGoogle Scholar
  64. 64.
    Hope DA, Herbert JD, White C. Diagnostic subtype, avoidant personality-disorder, and efficacy of cognitive-behavioral group-therapy for social phobia. Cognit Ther Res. 1995;19(4):399–417.CrossRefGoogle Scholar
  65. 65.
    Huppert JD, Strunk DR, Ledley DR, Davidson JR, Foa EB. Generalized social anxiety disorder and avoidant personality disorder: structural analysis and treatment outcome. Depress Anxiety. 2008;25(5):441–8.CrossRefPubMedGoogle Scholar
  66. 66.
    Oosterbaan DB, van Balkom AJ, Spinhoven P, de Meij TG, van Dyck R. The influence on treatment gain of comorbid avoidant personality disorder in patients with social phobia. J Nerv Ment Dis. 2002;190(1):41–3.CrossRefPubMedGoogle Scholar
  67. 67.
    Liebowitz MR, Gorman JM, Fyer AJ, Klein DF. Social phobia. Review of a neglected anxiety disorder. Arch Gen Psychiatry. 1985;42(7):729–36.CrossRefPubMedGoogle Scholar
  68. 68.
    Herbert JD, Gaudiano BA, Rheingold AA, Myers VH, Dalrymple K, Nolan EM. Social skills training augments the effectiveness of cognitive behavioral group therapy for social anxiety disorder. Behav Ther. 2005;36(2):125–38.CrossRefGoogle Scholar
  69. 69.•
    Renner F, van Goor M, Huibers M, Arntz A, Butz B, Bernstein D. Short-term group schema cognitive-behavioral therapy for young adults with personality disorders and personality disorder features: associations with changes in symptomatic distress, schemas, schema modes and coping styles. Behav Res Ther. 2013;51(8):487–92. This pilot study determined the effects of group schema therapy in patients with personality disorder. Global distress and underlying vulnerabilities in terms of maladaptive schemas decreased from pre- to post-treatment. CrossRefPubMedGoogle Scholar
  70. 70.
    Ahmed U, Gibbon S, Jones Hannah F, Huband N, Ferriter M, Völlm Birgit A et al. Psychological interventions for avoidant personality disorder. Cochrane Database Syst Rev. 2014 doi: 10.1002/14651858.CD009549.pub2
  71. 71.
    Ahmed U, Gibbon S, Jones Hannah F, Huband N, Ferriter M, Völlm Birgit A et al. Pharmacological interventions for avoidant personality disorder. Cochrane Database Syst Rev. 2014 doi: 10.1002/14651858.CD009304.pub2

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© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Anna Weinbrecht
    • 1
  • Lars Schulze
    • 1
  • Johanna Boettcher
    • 1
  • Babette Renneberg
    • 1
  1. 1.Clinical Psychology and PsychotherapyFreie Universität BerlinBerlinGermany

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