Avoidant Personality Disorder + Obsessive-Compulsive Personality Disorder - DSM-5

Diagnostic Criteria [AVPD]

pervasive pattern of social inhibition, feelings of inadequacy, + hypersensitivity to negative evaluation, beginning by early adulthood + present in a variety of contexts. requires 4+ symptoms.

1. avoidance of occupational activities that involve significant interpersonal contact because of fears of criticism, disapproval, or rejection

2. unwillingness to get involved w/ people unless certain that they’ll be liked

3. restraint in intimiate relationships bc of fear of being ashamed / ridiculed

4. preoccupation w/ being criticised / rejected in social situations

5. inhibited in new interpersonal situations because they feel inadequate

6. self-perception as socially inept, personally unappealing, or inferior to others

7. unusually reluctant to take personal risks or engage in new activities in case of embarrassment

Diagnostic Features [AVPD]

• other people are assumed to be critical + disapproving until they pass intense tests proving otherwise

• tend to be shy, quiet, inhibited, + “invisible” because any attention feels critical / rejecting

• for some, doubts about social competense are most intense w/ strangers; for others, repeated interactions are harder due to increased likelihood of inferiority being revealed w/ each interaction

• may exaggerate potential dangers of ordinary situations

• as commitments require repeated interpersonal interactions, individual may feel growing certainty over weeks / months that others see them as worthless → intolerable distress / anxiety → resignation from commitment

  • history of repeated job changes may be present

Associated Features [AVPD]

• hypervigilance of movements + expressions of people they come into contact w/

• major issues w/ social + occupational functioning

• relatively isolated w/ v. small support network

• desire affection + acceptance; may fantasise about idealised relationships w/ others

• insecure attachment styles

  • desire for emotional attachment clashes w/ fear of devaluation / harm from others → response of passivity, anger, fear: “preoccupied” or “fearful” attachment pattern

Prevalence [AVPD]

• estimated prev: 5.2%

• median prev: 2.1%

• more common in women than men — difference is small but consistent

Development + Course [AVPD]

• often starts in infancy / childhood w/ shyness, isolation, & fear of strangers + new situations

• instead of dissipating like normative shyness, becomes increasingly shy + avoidant during adolescence + early adulthood

• tends to become less avoidant or remit w/ age; prev. in 65+ is .8%

• should be diagnosed v. cautiously in kids + teens, when shy + avoidant behaviours may be developmentally appropriate

Culture-Related Diagnostic Issues [AVPD]

• variation in amount that different cultural + ethnic groups see diffidence + avoidance as appropriate

• avoidant behaviour may be result of problems adapting to new culture after migration

• in some sociocultural contexts, avoidance occurs after social embarrassment / failure to meet major life goals, not shyness — minimisation of social interactions to preserve social harmony / prevent public offense

Differential Diagnoses [AVPD]

• social anxiety disorder

• agoraphobia

• other personality disorders + personality traits

• personality change due to another medical condition

• substance use disorders

Differential Diagnosis: Social Anxiety Disorder [AVPD]

lots of overlap. has been suggested they’re different manifestations of similar underlying problems, or that AVPD may be a more severe form of SAD

differences found in self-concept: negative self-concept in SAD may be unstable, less pervasive + entrenched than AVPD. studies have shown AVPD freq. occurs in absence of SAD + there are some separate risk factors

Differential Diagnosis: Agoraphobia [AVPD]

overlap in avoidance. often co-occurring

distinguished by motivation for avoidance: fears of panic / physical harm in agoraphobia vs fears of criticism / judgement / negative evaluation in AVPD

Differential Diagnosis: Other Personality Disorders + Personality Traits [AVPD]

may have overlap in some features — important to distinguish personality disorders by differences in characteristic features. if a patient has personality features meeting criteria for 1+ personality disorders in addition to AVPD, all can be diagnosed

• dependent personality disorder: overlap in feelings of inadequacy, hypersensitivity to criticism, need for reassurance. also some overlap in behaviours + attributes (unassertiveness, low self-esteem + self-confidence), but some behaviours diverge (proximity avoidance in AVPD vs. proximity seeking in DPD). motivations also tend to differ — unassertiveness in AVPD stems from fears of rejection / humiliation, whereas DPD stems from desire to avoid being left to fend for self. likely to be comorbid

• schizoid personality disorder + schizotypal personality disorder: overlap in social isolation. people w/ AVPD desire relationships w/ others + feel deep loneliness, while schizotypal + schizoid people may be content w/ + even prefer isolation

• paranoid personality disorder: overlap in reluctance to confide in others. in AVPD, more attributable to fear of humiliation or being seen as inadequate than fear of malicious intent from others

many people also have avoidant traits. it is only indicative of AVPD when those traits are inflexible, maladaptive, persisting, + causing significant functional impairment / distress

Differential Diagnosis: Personality Change Due to Another Medical Condition [AVPD]

emerging traits will be the direct physiological consequence of another medical condition

Differential Diagnosis: Substance Use Disorders [AVPD]

must be distinguished from symptoms that develop in assoc. w/ persistent substance use

Comorbidity [AVPD]

• depressive + anciety disorders, esp. social anxiety disorder

• schizoid personality disorder

• increased rate of substance use disorders (similar to rate of SUD comorbidity in SAD)

Diagnostic Criteria [OCPD]

pervasive pattern of preoccupation w/ orderliness, perfectionism, & mental + interpersonal control at the expense of flexibility, openness, & efficiency, beginning by early adulthood + present in a variety of contexts. requires 4+ symptoms

1. preoccupation w/ details, rules, lists, order, organisation, or schedules to extent that the major point of the activity is lost

2. perfectionism that interferes w/ task completion

3. excessive devotion to work + productivity to the exclusion of leisure activities + friendships (outside of obvious economic necessity)

4. overconscientious, scrupulous, & inflexible about matters of morality, ethics, or values (outside of cultural or religious identification / norms)

5. inability to throw out worn-out / worthless objects even when they have no sentimental value

6. reluctance to delegate tasks or work w/ others unless they submit to exactly the individual’s way of doing things

7. adoption of miserly spending style toward self + others — money seen as something to hoard for future catastrophes

8. rigidity + stubbornness

Diagnostic Features [OCPD]

• excessively careful + prone to repetition, pay extraordinary attention to detail + repeatedly check for possible mistakes, losing track of time in the process

• dismiss others’ irritation at delays + inconveniences from their behaviour, preferentially responding to their own anxiety about mistakes or insistence on procedures

• time is poorly managed; most important things are left til the last moment

• discomfort during leisure activities / vacations unless they’ve taken along something to work on so they don’t “waste time”

• turn play / hobbies into structured, work-like tasks

• rigid deference to authority + rules, literal compliance w/ no rule-bending for extenuating circumstances

Associated Features [OCPD]

• extreme difficulty w/ decision-making

• prone to anger / upset when they can’t keep control of their environment, but anger is rarely expressed directly

• extremely attentive to status in power-imbalanced relationships: excessive deference to authorities they respect + excessive resistance to authorities they don’t

• difficult relating to + sharing emotions, intolerant of displays of emotion in others

• preoccupied w/ logic + intellect

• occupational difficulties + distress, esp. when faced w/ new situations requiring flexibility + compromise

Prevalence [OCPD]

• est. prev. = 2.4%

• median prev. = 4.7%

• equally prev. in men + women

Culture-Related Diagnostic Issues [OCPD]

• shouldn’t include behaviours reflecting culturally normative habits, customs, or interpersonal styles when assessing

Differential Diagnoses [OCPD]

• obsessive-compulsive disorder

• hoarding disorder

• other personality disorders + personality traits

• personality change due to another medical condition

• substance use disorders

Differential Diagnosis: Obsessive-Compulsive Disorder [OCPD]

distinguished by presence of true obsessions + compulsions in OCD. if criteria for both disorders are met, both should be diagnosed

Differential Diagnosis: Hoarding Disorder [OCPD]

should be considered when hoarding (criterion 5) is extreme (eg: fire hazard, difficult to navigate environment). if criteria for both disorders are met, both should be diagnosed

Differential Diagnosis: Other Personality Disorders and Traits [OCPD]

may have overlap in some features — important to distinguish personality disorders by differences in characteristic features. if a patient has personality features meeting criteria for 1+ personality disorders in addition to OCPD, all can be diagnosed

• narcissistic personality disorder: overlap in perfectionism + belief that others can’t do things as well as they can, but people w/ NPD are more likely to think that they’ve achieved perfection while people w/ OCPD are usually self-critical. while both may lack generosity, people w/ NPD also tend to indulge themselves while people w/ OCPD won’t spend on themselves either

• antisocial personality disorder: while both may lack generosity, people w/ ASPD tend to indulge themselves while people w/ OCPD won’t spend on themselves either

• schizoid personality disorder: overlap in apparent formality + social detachment. in OCPD, this stems from discomfort w/ emotions + excessive devotion to work, while in SPD it stems from a fundamental lack of capacity for intimacy

many people also have obsessive-compulsive traits. they can be highly adaptive, especially in situations that reward high performance. it is only indicative of AVPD when those traits are inflexible, maladaptive, persisting, + causing significant functional impairment / distress

Differential Diagnosis: Personality Change Due to Another Medical Condition [OCPD]

emerging traits will be the direct physiological consequence of another medical condition

Differential Diagnosis: Substance Use Disorders [OCPD]

must be distinguished from symptoms that develop in assoc. w/ persistent substance use

Comorbidity [OCPD]

• people w/ anxiety disorders + OCD have increased likelihood of personality disturbance meeting criteria for OCPD

  • still, most people w/ OCD don’t meet criteria for OCPD

• lots of overlap w/ “type A” personality characteristics — may be present in people at risk for myocardial infarction (heart attack)

• possible association w/ depressive, bipolar, & eating disorders