Avoidant Personality Disorder

and Social Phobia

Studies of Personality Pathology and Functioning, Childhood
Experiences and Adult Attachment

Ingeborg Helene Ulltveit-Moe Eikenæs

Faculty of Medicine
UNIVERSITY OF OSLO
2016
© Ingeborg Ulltveit-Moe Eikenæs, 2016

Series of dissertations submitted to the

Faculty of Medicine, University of Oslo

ISBN 978-82-8333-186-8

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form or by any means, without permission.

Cover: Hanne Baadsgaard Utigard

Printed in Norway: 07 Media AS – www.07.no
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INDEX

1. Overview

1.1 Summary………………………………………………………………….. s.3

1.2 List of papers……………………………………………………………… s.6

1.3 Acknowledgements……………………………………………………….. s.6

1.4 Abbreviations……………………………………………………………… s.7

2. Introduction

2.1 Avoidant Personality Disorder……………………………………………… s.9

2.1.1 Historical development and definition……………………………….. s.9

2.1.2 Prevalence and clinical characteristics……………………………… s.13

2.1.3 Treatment and prognosis…………………………………………….. s.16

2.2 Social Phobia/Social Anxiety Disorder…………………………………….. s.18

2.3 The relationship between Avoidant Personality Disorder and Social Phobia s.22

2.4 Personality functioning……………………………………………………... s.26

2.5 Constitutional factors………………………………………………………. s.29

2.5.1 Heritability…………………………………………………………… s.29

2.5.2 Temperament........................................................................................ s.30

2.6 Childhood experiences……………………………………………………… s.31

2.7 Attachment………………………………………………………………….. s.35

2.7.1 Adult attachment……………………………………………………… s.36

2.7.2 Attachment studies on AvPD…………………………………………. s.37

2.7.3 Attachment studies on SP…………………………………………….. s.38

2.8 Experience in Close Relationship inventory, ECR. Psychometric properties.s.39

3. Aims and hypotheses

3.1 Main aims…………………………………………………………………… s.42

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3.2 Specific aims, hypotheses, and research questions………………………… s.43

4. Methods

4.1 Settings, design and samples………………………………………………. s.44

4.2 Assessments by interviews: Axis I and Axis II diagnoses……………………s.45

4.3 Assessments by self-report instruments…………………………………….. s.47

4.3.1 Personality functioning………………………………………………. s.47

4.3.2 Symptoms…………………………………………………………….. s.48

4.3.3 Work and social functioning………………………………………….. s.48

4.3.4 Quality of life…………………………………………………………. s.49

4.3.5 Childhood experiences……………………………………………….. s.49

4.3.6 Temperament………………………………………………………… s.50

4.3.7 Attachment style.....................................................................................s.50

4.4 Statistics…………………………………………………………………… s.51

4.5 Participants…………………………………………………………………. s.53

5. Results

5.1 Paper I ……………………………………………………………………… s.54

5.2 Paper II……………………………………………………………………… s.55

5.3 Paper III…………………………………………………………………….. s.56

5.4 Paper IV……………………………………………………………………...s.57

6. Discussion

6.1 Main findings………………………………………………………………...s.58

6.1.1 Personality pathology and functioning………………………………...s.58

6.1.2 Childhood experiences and temperament……………………………...s.62

6.1.3 Attachment styles……………………………………………………….s.64

6.2 Methodological issues; strengths and limitations of papers I, II, and IV…….s.68
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6.2.1 Design ………………………………………………………………….s.68

6.2.2 Sample…………………………………………………………………..s.68

6.2.3 Statistics....................................................................................................s.70

6.2.4 Assessments……………………………………………………………..s.71

6.3 Psychometrics of ECR in a sample of personality disorders………………….s.73

6.4 Clinical implications……………………….…………………………………..s.75

6.5 Implications for further research………………………………………………s.77

7. General conclusions………………..…………………………………………..s.78

8. References………………………………………………………………………..s.80

1. OVERVIEW

1.1 Summary

Background: Avoidant Personality Disorder (AvPD) and Social Phobia (SP) are

closely related and common disorders both in the community and in clinical settings.

Whether the two disorders represent different severity levels of social anxiety disorder is

currently in dispute. The relationship between AvPD and SP is probably more complex

than previously assumed. Little is known about similarities and differences in personality

functioning and psychopathology, temperamental and environmental factors, and the

underlying processes related to social discomfort in subjects with AvPD and/or SP, such

as attachment styles. We wanted to use the Experiences in Close Relationships (ECR)

inventory to assess attachment style; however, the Norwegian version of ECR has

previously not been tested in a sample of patients with personality disorders (PDs).

Objectives: This thesis aimed to explore differences and similarities in developmental

and psychopathological aspects of AvPD and SP through comparison of symptoms,

personality pathology and functioning, temperament, childhood experiences/trauma, and

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attachment styles in patients with AvPD and SP. In this way, we hope to contribute to a

more thorough understanding of the psychopathology of AvPD and the relationship

between the two disorders. By investigating the psychometric properties of the Norwegian

version of ECR in a sample of PDs, we were able to use this instrument to compare

attachment styles in AvPD and SP.

Materials and methods: Papers I, II, and IV are based on a sample of 91 adult patients

with AvPD and/or SP who participated in a multi-site, cross-sectional study. In paper I,

we compared three diagnostic groups: one group of patients who had SP and not AvPD; a

group who had AvPD and not SP; and a group of patients who had both diagnoses. In

papers II and IV, we merged all of the patients with AvPD into one AvPD group with and

without concurrent SP and compared them to patients with SP without AvPD, designated

as the SP group. Ninety percent of patients in the SP group had generalized SP. Patients

were examined using diagnostic interviews and self-report measures, including the Index

of Self-Esteem, Severity Indices of Personality Problems, Adult Temperament

Questionnaire, Childhood Trauma Questionnaire, Parental Bonding Instrument, and the

ECR inventory. In paper III, we examined the psychometric properties of ECR and its two

short-forms, ECR-S and ECR-N12, in a sample of 495 patients with PDs. Analyses of the

internal consistency, as well as confirmatory and exploratory factor analyses, were

conducted.

Results: Papers I, II, and IV – Compared with the SP group, patients with AvPD had

more symptom disorders and met more criteria for other PDs. They reported more

psychosocial problems and more personality dysfunction regarding self-esteem, identity,

and relational problems. AvPD predicted personality dysfunction in the identity and

relational domains over and above the presence of SP, number of other symptom

disorders, and other PDs.

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Both AvPD and SP were associated with negative childhood experiences. Patients

with AvPD reported more severe childhood neglect, most pronounced for physical

neglect, compared to patients with SP without AvPD. The difference between the

disorders in neglect remained significant after controlling for temperamental differences

and concurrent physical, sexual, and emotional abuse. Both SP and AvPD were associated

with high levels of attachment anxiety and avoidance, and a large majority of patients in

both groups had an insecure attachment style. Patients with AvPD had higher levels of

attachment anxiety than patients with SP without AvPD, especially regarding the sub-

factors “Anxiety for abandonment” and “Separation frustration.” Severity of AvPD was

associated with “Anxiety for abandonment” over and above concurrent SP, the number of

other symptom disorders, and criteria met for other PDs. The diagnostic groups did not

differ significantly in levels of attachment avoidance.

Paper III – The internal consistency of ECR was found to be questionable.

Confirmatory factor analyses revealed poor model fit for the two factor solution of ECR

and ECR-S. The two factor solution of ECR-N12 revealed mediocre fit, indicating a

potential for improvement. An exploratory factor analysis indicated five factors

representing two somewhat different aspects of attachment avoidance and three aspects of

attachment anxiety. This alternative five factor solution was called ECR-FF.

Conclusions: Papers I, II, and IV – The results indicate that AvPD involves broader

and more severe areas of personality pathology and dysfunction than SP, supporting the

conceptualization of AvPD as a PD. Furthermore, childhood neglect could be a risk factor

for AvPD and SP, most pronounced for AvPD, and may be one contributing factor to

phenomenological differences between AvPD and SP. AvPD seems to be associated with

more attachment anxiety than SP. Thus, fear of abandonment may play a significant role

in avoidant personality pathology. Paper III – Inferences from scale scores based on ECR
 6

should be derived with care in samples with PDs. A revision of ECR and ECR-N12 is

warranted, and further studies are needed to investigate the validity of ECR-FF among

different clinical samples.

1.2 List of papers

I. Eikenaes, I., Hummelen, B., Abrahamsen, G., Andrea, H., & Wilberg, T. (2013).

Personality Functioning in Patients with Avoidant Personality Disorder and Social

Phobia. Journal of Personality Disorders, 27: 746-63.

DOI:10.1521/pedi_2013_27_109

II. Eikenaes, I., Egeland, J., Hummelen, B., Wilberg, T. (2015). Avoidant Personality

Disorder Versus Social Phobia: The Significance of Childhood Neglect. PLoS

ONE, 10(3): e0122846. DOI:10.137/journal.pone.0122846

III. Pedersen, G., Eikenæs, I., Urnes, Ø., Skulberg, G. M., & Wilberg, T. (2015).

Experiences in Close Relationships – Psychometric Properties Among Patients

with Personality Disorders. Personality and Mental Health, 9(3): 208-19.

DOI:10.1002/pmh.1298

IV. Eikenæs, I., Pedersen, G., & Wilberg, T. (2015). Attachment Styles in Patients with

Avoidant Personality Disorder Compared with Social Phobia. Psychology and

Psychotherapy: Theory, Research and Practice, Aug 31. DOI:10.1111/papt.12075

1.3 Acknowledgements

I want to thank:

- Each of the 91 patients who participated in this study for their willingness, time, and

confidence, making the study possible. I’ve promised them to use the results in
 7

support of a better understanding of AvPD and SP. In the longer run, the results will

hopefully be used to develop more efficient treatment programs that could improve the

outcome for patients with AvPD.

- My supervisors Theresa Wilberg, Jens Egeland, and Egil Martinsen for their wise

guidance with kindness, support, and great patience. Theresa has been my first

supervisor. She is continuously focused on quality and has a genuine interest in these

topics herself, which has been inspiring and trust-building for me.

- Vestfold Hospital Trust, division of addiction and mental health, for the economic and

practical foundation of this project, making this study possible.

- My co-authors Gun Abrahamsen, Helene Andrea, Benjamin Hummelen, Geir

Pedersen, Øyvind Urnes, and Guro Mikaelsen Skulberg for their inspiring

contributions.

- Secretaries Dagny Aamot, Synnøve Heum, and Nina Tapio, librarians Mariann

Mathisen and Brit Dolve Larsen, and information technology adviser Amund Ose-

Johansen, for help of great value.

- My colleagues at the unit of group psychotherapy in Tønsberg where I have my

weekly clinical work, for their interest, patience, kindly support, and contributions.

- Senior researchers Tore Gude, Asle Hoffart, Sven Torgersen, and Andrew Skodol for

inspiring me to start and continue research in this field.

- Most of all, I’m deeply thankful to God, my parents Else-Marie and Andreas, my

husband Einar, our children Nora Marie, Hjørund, and Audun, my two sisters Tone

and Åse, and my close friends and colleagues for their confidence, support, and

patience.

1.4 Abbreviations
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AAI Adult Attachment Interview

AMPD Alternative Model of Personality Disorders

ANCOVA Analysis of covariance

ANOVA Analysis of variance

APA American Psychiatric Association

AvPD Avoidant Personality Disorder

ATQ Adult Temperament Questionnaire

BPD Borderline Personality Disorder

CBT Cognitive Behavioral Therapy

CFA Confirmatory Factor Analysis

CIP Circumplex of Interpersonal Problems

CTQ Childhood Trauma Questionnaire

DSM Diagnostic and Statistical Manual of Mental Disorders

ECR Experiences in Close Relationships

ECR-FF Five Factor Model of ECR

ECR-N12 Short version of ECR (Norwegian)

ECR-S Short version of ECR (Iowa, USA)

GAF Global Assessment of Functioning

GSI General Symptom Index (SCL-90-R)

GSP Generalized Social Phobia

ICD International Classification of Diseases

IIP Inventory of Interpersonal Problems

IPT Interpersonal Psychotherapy

ISE Index of Self Esteem

M.I.N.I. Mini International Neuropsychiatric Interview

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PBI Parental Bonding Instrument

PD Personality Disorder

PD NOS Personality Disorder Not Otherwise Specified

RCT Randomized Controlled Trials

SAD Social Anxiety Disorder

SCID-II Structural Clinical Interview for DSM-IV Axis II Personality Disorders

SCL-90-R Symptom Check List 90 – Revised

SIPP-118 Severity Indices of Personality Problems

SP Social Phobia

SSP Specific/ Simple SP

UPP Ullevål Personality Project

WHO World Health Organization

WSAS Work and Social Adjustment Scale

2 INTRODUCTION

2.1 Avoidant Personality Disorder

2.1.1 Historical development and definition

Theodor Millon could be regarded as the father of the diagnosis of Avoidant Personality

Disorder (AvPD). Later definitions are based on his, and he was the first to name the disorder

Avoidant Personality Disorder. From his biosocial and learning theoretical perspective, he

described an “active–detached” personality pattern, opposed to the “passive–detached”

pattern, as two types of the schizoid personality (Millon, 1969). Later, he referred to AvPD as

a pervasive disorder that affects the whole life and personality with somatic, emotional,

cognitive, and behavioral disturbances, including avoidant strategies to reduce pain in all of

these areas (Millon, 1981). Millon played a decisive role when the disorder was included for
 10

the first time in the Diagnostic and Statistical Manual for Mental Disorders, DSM (DSM-III,

American Psychiatric Association, APA, 1980).

According to Millon (1991), the first to approximate the AvPD character was Eugen

Bleuler in 1911. Bleuler described patients who “quite consciously shun contact with reality

because their affects are so powerful that they must avoid everything which might arouse their

emotions” (Bleuler, 1911). Ernst Kretschmer elaborated the hyperaesthetic extreme of the

schizoid temperament in his book Physique and Character (Kretschmer, 1925) as a person

who “behaves shyly, or timidly, or distrustfully…, seeks as far as possible to avoid and

deaden all stimulation from the outside.” Later psychoanalytic theorists such as Ronald

Fairbairn (1940) and Donald W. Winnicott (1956) formulated concepts like “schizoid” and

“false self” resembling AvPD. Karen Horney in her book Our Inner Conflicts (Horney, 1945)

also described a “detached type” with an interpersonal style of “moving away from people”,

akin to AvPD. Moreover, Otto Fenichel’s elaboration of the “phobic character” (Fenichel,

1945) and the early object-relation theorists writing about the “need–fear dilemma”

(Burnham, Gladstone, & Gibson, 1969) – longing for closeness combined with a fear of

intimacy – have contributed to the conceptualization of AvPD. In DSM-III (APA, 1980),

AvPD was for the first time distinguished from the restricted affectivity and interpersonal

indifference of the Schizoid PD. Later Aron Beck and Arthur Freeman (Beck & Freeman,

1990) described AvPD in similar ways as an extensive disorder with behavioral, affective, and

cognitive avoidance patterns.

The present thesis is based on the diagnostic definitions in DSM-IV (APA, 1994) in

which a PD in general is defined by the following criteria:

An enduring pattern of inner experience and behavior that deviates

markedly from the expectations from the individual’s culture and is

manifested in at least two of the following areas:

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 Cognition (i.e., ways of perceiving and interpreting self, others,

and events)

 Affectivity (i.e., the range, intensity, lability, and appropriateness)

 Interpersonal functioning or

 Impulse control

The enduring pattern is stable and of long duration, and its onset can be

traced back at least to adolescence or early adulthood. The pattern is

inflexible and pervasive across a broad range of personal and social

situations and leads to clinically significant distress or impairment in

social, occupational, or other important areas of functioning.

DSM-IV also defines some exclusion criteria: The enduring pattern is not better

accounted for as a manifestation or consequence of another mental disorder and is not due to

the direct physiological effects of a substance or a general medical condition. In keeping with

its definition, PDs have traditionally been considered chronic; however, several longitudinal

studies during the last decades have added considerable nuance to this perception of stability

(Cohen, Crawford, Johnson, & Kasen, 2005; Hopwood et al., 2013; Lenzenweger, 2006;

Skodol, 2008; Zanarini et al., 2015). For example, the Collaborative Longitudinal Personality

Disorders Study documented high diagnostic remission rates and low rates of relapse but high

stability of impairment in social functioning over 10 years (Gunderson et al., 2011). In the

same sample, half of the patients with AvPD lost their diagnosis after two years, i.e. the

criteria dropped below the diagnostic threshold, independently of level of care or amount of

treatment (Grilo et al., 2004a).

In the DSM-IV, AvPD is one of eleven PD diagnoses, including PD not otherwise

specified (PD NOS). AvPD is described as a pervasive pattern across time and situations,

starting in early adulthood, and characterized by social inhibition because of feelings of

 12

inadequacy and hypersensitivity to negative evaluation indicated by at least four of seven

criteria (Table 1). In addition, the person has to meet the general criteria for a PD, as

described above, to qualify for the diagnosis of AvPD. The International Classification of

Diseases (ICD-10; World Health Organization, WHO, 1992) refers to the disorder as “anxious

(avoidant) personality disorder” and describes many of the same characteristics as DSM-IV

but requires only three of the criteria to be present to qualify for a diagnosis. Anxious PD was

for the first time included in ICD-9 (WHO, 1978).

Insert table 1 about here

Major changes have been made in the definition of AvPD from DSM-III up to DSM-

IV and DSM-5. Criteria have been omitted, changed, and reintroduced. For example, in DSM-

III-R (APA, 1987), low self-esteem, desire for affection and acceptance, and hypersensitivity

to rejection were downplayed whereas fear of being inappropriate or embarrassed was added,

thus approaching the definition of SP. In DSM-IV, the criterion of low self-esteem was

reintroduced, and a criterion of being restrained in intimate relationships was introduced. In

DSM-III, a diagnosis of AvPD excluded the diagnosis of SP, so that co-occurrence was not

diagnosed. The omission of this hierarchy from DSM-III-R and onward was another major

change relevant for AvPD. Likewise, the introduction of the diagnostic specifier ‘generalized

SP’ (GSP) in DSM-III-R, defining GSP as fears in most social situations, has brought the

diagnostic constructs even closer together and increased the diagnostic overlap. From DSM-

III (APA, 1980) until DSM-IV-TR (APA, 2000), AvPD was placed in cluster C (Avoidant,

Dependent, and Obsessive–Compulsive PD – “the fearful” PDs) on Axis II along with other

PDs. Symptom disorders were placed on Axis I. With the advent of DSM-5 (APA, 2013), the

longstanding multiaxial system for mental disorders was eliminated. Yet, in DSM-5 (APA,

2013), the definition of AvPD from DSM-IV is retained. However, there is an Alternative

Model of Personality Disorders in DSM-5 (DSM-5-AMPD; APA, 2013), in which AvPD is

 13

one of six specific PD prototypes and is described as a negative sense of self with excessive

feelings of shame and inadequacy, social withdrawal, intimacy avoidance, anhedonia and

anxiousness, in which anxiousness is compulsory (APA, 2013).

The validity as a prototype category and the psychometric properties of AvPD in

DSM-IV have been investigated in different clinical samples (Becker, Añez, Paris, Bedregal,

& Grilo, 2009; Grilo, 2004b; Hummelen, Wilberg, Pedersen, & Karterud, 2006). The three

studies agree on a one factor solution accounting for a majority of the variance in the criteria,

high internal consistency, and good diagnostic efficiency.

2.1.2 Prevalence and clinical characteristics

AvPD is a common disorder and is one of the most prevalent PDs. In clinical settings,

prevalence estimates range from 11% to 57% (Hummelen et al., 2007; McGlashan et al.,

2000; Soeteman, Hakkaart-van, Verheul, & Busschbach, 2008; Verheul, Bartak, & Widiger,

2007), and in the general population from 0.5% to 5% (Torgersen, Kringlen, & Cramer,

2001). AvPD has traditionally been regarded as a less severe PD (Kernberg, 1996; Millon,

1981). Skodol et al. (2002) found that patients with AvPD have functional impairment at an

intermediate level, between patients with Borderline PD and Obsessive–Compulsive PD.

However, more recent data show that AvPD could be associated with significant psychosocial

impairment, similar to Borderline PD (Cramer, Torgersen, & Kringlen, 2007; Hopwood et al.,

2006; Lynum, Wilberg, & Karterud, 2008; Wilberg, Karterud, Pedersen, & Urnes, 2009).

In an Australian national survey of mental health and well-being, compared with

persons without any PD, patients with AvPD had about two times increased odds for one or

more physical conditions, about six times for one or more Axis I disorders, and about seven

times for having high disabilities due to mental problems (Jackson & Burgess, 2004). In a

large Norwegian population study, Cramer et al. found that AvPD appeared to be an
 14

important predictor of poor quality of life, more important than sociodemographic variables,

somatic health, and Axis I disorders (Cramer et al., 2007). In another Norwegian community

study, Olssøn and Dahl (2012) found that persons with “avoidant personality problems”

(including subthreshold AvPD) often reported living alone, having somatic diseases, physical

inactivity, daily smoking and alcohol problems, insomnia that affected work ability, a lower

level of education, and lower income. Moreover, in the clinical PD sample of Wilberg et al.

(2009), patients with AvPD had a lower level of global functioning, higher level of

interpersonal problems, and lower level of social support compared with patients with

Borderline PD, Paranoid PD, Dependent PD, Obsessive–Compulsive PD, and PD NOS. Thus,

AvPD is associated with substantial clinical and socioeconomic impairments.

The medical term ‘comorbidity’ is often used to describe co-variation among mental

disorders, i.e., the presence of two or more distinct disorders (Feinstein, 1970). However, our

understanding of mental disorders has not yet reached the level at which the disorders can be

described with true distinction. Hence, along with Krueger (2005), we will use the terms

‘diagnostic co-occurrence’ or ‘concurrent diagnoses’ in this thesis. Clinical samples have a

high co-occurrence of symptom disorders such as depression, anxiety disorders, eating

disorders, and alcohol and substance use disorders in patients with AvPD (Eikenaes, Gude, &

Hoffart, 2006; Johansen, Normann-Eide, Normann-Eide, & Wilberg, 2013; Ralvski et al.,

2005). They also have a high rate of other concurrent PD diagnoses like Dependent,

Borderline, Schizoid, and Paranoid PDs (Hummelen et al., 2007; Wilberg et al., 2009). Thus,

patients with AvPD present a large variation in psychopathology. Moreover, there are 62

possible different combinations of the four AvPD criteria required to meet the diagnosis

(Hummelen et al., 2006). Differing severities of each criterion and the overall personality

dysfunction may vary as well. Patterns of co-occurring Axis I and Axis II diagnoses, the total

extent of pathology, different attachment patterns, and interpersonal styles may also
 15

contribute to the heterogeneity among patients with AvPD. In addition, AvPD may include

underlying dimensions not related to social anxiety, such as genetic and neurocognitive

aspects associated with the schizophrenia spectrum (Asarnow et al., 2001; Fogelson et al.,

2010; Foegelson et al., 2007) and lack of social skills associated with autism spectrum

disorders like Asperger’s disorder (Lunegard, Hallerback, & Gillberg, 2012).

Emotional dysfunction seems to be an important feature of AvPD. Low affect

tolerance, avoidance of emotions, dysfunctional beliefs about emotions, and a general affect

phobia have been proposed (Beck & Freeman, 1990; McCullough et al., 2003; Millon, 1981).

More recently, the metacognitive theory of DiMaggio and coworkers (2007) claims that

patients with AvPD have profound difficulty identifying their own mental states with respect

to both emotions and thoughts, and a subsequent impaired ability to convey their experiences,

partly linked to alexithymia (Diamaggio, Popolo, & Salvatore, 2012; Nicolo et al., 2011;

Semerari et al., 2014). Alexithymia is defined as difficulties with identifying, interpreting, and

describing one’s emotions (Taylor, 2000). Taylor, Laposa, and Alden (2004) found emotional

and novelty avoidance to be associated with AvPD both in a clinical and a student sample.

Interestingly, patients with both GSP and AvPD scored higher on avoidance of positive

emotions compared with patients with GSP only and with healthy controls (Taylor et al.,

2004). In different samples, AvPD has been associated with a higher degree of negative

emotions and lower levels of positive emotions (Hummelen et al., 2007; Ye, Yao, Fu, &

Kong, 2011) and emotional inhibition (Popolo et al., 2014). Regarding specific affects,

Schoenleber and Berenbaum (2012) found that shame proneness predicted AvPD symptoms

in a large student sample.

The opposite of alexithymia is affect consciousness, defined somewhat broadly as the

capacity to perceive, reflect on, tolerate, and express emotional experiences. In a study of

affect consciousness, Johansen et al. (2013) found that patients with AvPD had lower levels
 16

of global affect consciousness and conceptual expressivity compared with patients with

Borderline PD. Among the 11 specific affects, patients with AvPD had lower affect

consciousness for interest and contempt. Besides these findings, little is known about

emotional dysfunction in AvPD.

2.1.3 Treatment and prognosis

So far, few studies have focused on treatment of AvPD. To our knowledge, only two

randomized controlled trials (RCTs) on AvPD are published (Alden, 1989; Emmelkamp et al.,

2006). In Alden’s 1989 study, 76 patients with AvPD participated in a 10-week behavioral

group treatment program. They were randomized to different social exposure strategies or a

waiting list. The patients in the treatment groups improved significantly more than those on

the waiting list, and the improvements were maintained at the 3-month follow-up. However,

the patients did not reach a normative level of functioning. Alden concluded that this short-

term intervention was of insufficient duration for these subjects to overcome their habitual

avoidant behavior, although improvement did occur. In a short-term (20 weeks) randomized

study of 62 patients with AvPD, Emmelkamp and co-workers (2006) found cognitive–

behavioral therapy (CBT) to be superior to brief psychodynamic treatment. The study

excluded patients with symptom disorders that required immediate treatment such as

depressive disorder, agoraphobia, and panic disorder, and those using medications. The

improvements in CBT were maintained at 6 months of follow-up. Social skills group training

as a treatment component for patients with AvPD did not seem to have any additional effect

on group treatment or individual treatment (Stravynski, Lesage, Marcouiller, & Elie, 1998;

Zimmermann et al., 2013)

In a naturalistic study of time-limited psychodynamic treatment with 52 sessions of

Supportive–Expressive psychotherapy, Barber and co-workers found that 60% of the 24

 17

patients with AvPD lost their PD diagnoses, compared with 85% of the 14 patients with

Obsessive–Compulsive PD. However, 46% of the patients with AvPD dropped out of

treatment, not completing 52 sessions. On average, the patients with AvPD stayed in

treatment for 35 sessions whereas patients with Obsessive–Compulsive PD stayed for 50

sessions (Barber, Morse, Krakauer, Chittams, & Crits-Christoph, 1997).

Some recent treatment studies have shown promising results for cluster C PDs

(Avoidant, Dependent, and Obsessive–Compulsive PDs), in which 51 to 63% of the patients

had AvPD (Bamelis, Evers, Spinhoven, & Arntz., 2014; Bartak et al., 2009; Svartberg, Stiles,

& Seltzer, 2004). In the study of Bamelis et al. (2014), 323 outpatients with PDs, mainly

cluster C, were randomly assigned to Schema-Focused individual therapy (SFT), Treatment as

usual (TAU), or Clarification-Oriented therapy (COT). The median total number of sessions

of indicated principal treatments over 3 years was 50 for SFT, 51 for COT, and 22 for TAU.

SFT was superior to the other therapies regarding diagnostic recovery after 3 years and drop-

out rate. Differences were not found for the self-report measures, however. Bartak et al.

(2009) studied the effectiveness of different treatment modalities for 371 patients with cluster

C PDs in a naturalistic multi-site project. Initial differences in patient characteristics were

controlled for statistically. Short-term inpatient treatment (up to 6 months) was superior to the

four other treatment modalities: long-term outpatient treatment (more than 6 months), short-

term day hospital treatment, long-term day hospital treatment, and long-term inpatient

treatment. Outcome was measured by self-reported symptoms, psychosocial functioning, and

quality of life. In the study of Svartberg et al. (2004), 50 patients with cluster C PDs, assessed

by Millon Clinical Multiaxial Inventory (Millon, & Davis, 1997), were randomly assigned to

40 weekly sessions of individual psychodynamic therapy or cognitive therapy. Effect sizes

were generally large both during treatment and follow-up for both therapies. No differences

were found between the therapies. Two years after treatment, 54% of those who received
 18

psychodynamic therapy and 42% of those receiving cognitive therapy had recovered

symptomatically whereas 40% in both treatment groups recovered in terms of interpersonal

problems and PD disorder. However, all outcome measures were self-report, and about 40%

had unchanged scores on all three outcome measures.

Finally, several treatment studies have identified AvPD as a negative prognostic factor

and associated with increased risk of relapse after treatment (Chiesa & Fonagy, 2003; Gude &

Vaglum, 2001; Karterud et al., 2003; Seemüller et al., 2014; Vrabel, Ro, Martinsen, Hoffart,

& Rosenvinge, 2010).

In summary, AvPD is a prevalent disorder associated with large heterogeneity and

extensive clinical and socioeconomic impairments, often with a negative prognosis. The

personal and health economic burden of AvPD is considerable. Yet, the specific pathology

and treatment of AvPD have rarely been the focus of systematic research; thus, we need to

understand more about this condition. This better understanding of the nature of the

psychopathology of AvPD could in the longer run lead to development of more efficient

treatments and to a more favorable prognosis for the disorder.

AvPD shares many similarities with SP. Differences and similarities between these

disorders have been discussed from the start, when they were included in the diagnostic

classification systems in 1978 and 1980, and are still disputed (Carter & Wu, 2010; Lampe &

Sunderland, 2013; Marques et al., 2012; Reich, 2014). Differences and similarities between

AvPD and SP are the topics of this thesis.

2.2. Social Phobia/Social Anxiety Disorder

The terms SP and Social Anxiety Disorder (SAD) are used interchangeably. In this

thesis, I have chosen to use SP, including when referring to studies that apply the term SAD.

SP was included in the diagnostic classification systems for the first time in ICD-9 (WHO,
 19

1978) and DSM-III (APA, 1980). We used DSM-IV (APA, 1994), which defines SP as shown

in Table 2.

Insert table 2 about here

DSM-IV defines similar exclusion criteria for SP as for PDs (page 11). There are two

main subtypes of SP: GSP and non-generalized SP, also called specific or simple SP (SSP).

For patients with GSP, almost all social situations elicit anxiety (e.g., in conversations,

meetings, parties, performances, and other interactions). In the non-generalized subtype, fears

are restricted to a few specific social situations. In ICD-10, there is no subtyping, and

physiologically related anxiety symptoms like blushing, hand tremor, nausea, and urgency for

micturition are emphasized. Individuals classified with SP by one of these classification

systems may not necessarily be diagnosed in the same category by the other system;

diagnostic concordance seems to range between 36 and 66% (Andrews, Slade, Peters, &

Beard, 1998).

In social or performance situations, persons with SP may experience physical

manifestations of anxiety, including blushing, sweating, trembling, and palpitations, which

sometimes can take the form of a full panic attack. They often fear that others will notice that

they are anxious. Persons with SP also experience anticipatory anxiety, worrying for hours or

days prior to a feared event. The degree and character of their avoidance behaviors may vary a

lot. They may completely avoid situations, becoming socially isolated, or they may participate

with intense anxiety, some merely with support from other people or other forms of safety

behaviors or with use of alcohol or tranquilizers. Upon leaving a social situation, persons with

SP often focus on their perceived shortcomings, berate themselves, and feel depressed

(Schneider, Stein, & Hermann, 2015).

 20

SP has a mean age of onset in the mid-teens (Kessler et al., 2005a). It often arises as

an intensification of pre-existing non-impairing shyness, although many patients with SP may

identify an unusual stressful social situation in which they felt ridiculed that triggered SP.

Onset after age 30 is uncommon. SP shows an enormous variation in rates of spontaneous

remission, indicating different courses: short, fluctuating, and chronic (Vriends, Bolt, & Kunz,

2014). Chronic SP is associated with early onset, concurrent psychiatric disorders, chronic

health problems, financial dependence, suicidal ideation, family problems, low social

functioning, and high society costs (Vriends et al., 2014). There are also large variations and

heterogeneity in chronic SP regarding co-occurrence of other psychiatric disorders. SP is a

risk factor for subsequent development of major depression and alcohol or substance

dependence (Beesdo et al., 2007; Schneier et al., 2010). Different levels of personality

functioning and different dysfunctional personality traits, maladaptive interpersonal styles,

and attachment patterns may also contribute to the heterogeneity among patients with SP but

are less or not studied at all.

SP is the most prevalent anxiety disorder with a lifetime prevalence ranging from 5 to

12% (Fehm, Pelissolo, Furmark, & Wittchen, 2005; Grant et al., 2005; Kessler et al., 2005b;

Stein et al., 2010). A review of long-term courses of SP showed that clinical samples had a

27% recovery rate after 5 years compared with 40% in non-clinical samples (Steinert,

Hofmann, Leichsenring, & Kruse, 2013). Skodol, Geier, Grant, and Hasin (2014) found that

some concurrent PDs, including AvPD, and severity of concurrent PDs predicted the

persistence of SP over 3 years in a large national sample from the United States.

There has been a lot of research on SP, and more effective treatments have been

developed, both psychological treatments, pharmacotherapy, and combinations (Blanco et al.,

2010; Blanco et al., 2003; Borge et al., 2008; Clark et al., 2003; Davidson et al., 2004;

Leichsenring, et al, 2014; Ravindran & Stein, 2010; Stein, Ipser, & Balkom, 2004).
 21

Pharmacologic treatment is quite different for GSP versus SSP. Antidepressants like SSRIs

and SNRIs (selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake

inhibitors, respectively) are the first-line medication treatment recommended for GSP, and

MAOIs (non-selective and irreversible monoamine oxidase inhibitors) are suggested as

second-line medication (Stein, Roy-Byrne, & Hermann, 2015). They need to be taken daily up

to 16 weeks to achieve full effect and continued for at least 6 to 12 months to prevent relaps.

SSRIs are best studied and the most commonly prescribed medication for SP (Ravindran &

Stein, 2010). Meta analyses of SSRIs to GSP show symptom reduction at a moderate effect

size (Stein et al., 2004). Although debated, non-generalized SP is often recommended to be

treated with medication rather than psychotherapy, with a benzodiazepine or beta-adrenergic

blocker taken before entering the feared situations (Stein et al., 2015).

The most widely studied of contemporary psychological theories of SP emphasize the

role of cognitive processes in the generation and maintenance of SP in vulnerable people.

These models are the bases for CBT. Therapeutic strategies include psychoeducation,

cognitive restructuring, and exposure practice, usually in 12 and up to 20 weeks. CBT is given

in different modalities, as individual therapy, group therapy, and internet-guided courses.

Stangier, Heidenreich, Peitz, Lauterbach, and Clark (2003) found that CBT given as

individual therapy was more efficious than group therapy in a sample of 71 patients with SP

treated in fivteen weeks. A meta-analysis of RCTs found CBT to be moderately efficacious

for SP, with considerable variation in effect sizes across studies (Hofmann & Smits, 2008).

RCTs comparing CBT and pharmacotherapy for SP have not demonstrated superiority of one

treatment over the other (Davidson et al., 2004). Trials comparing the combination of CBT

and antidepressant medication for SP to either treatment individually have shown mixed

results (Davidson et al., 2004; Blanco et al., 2010).

 22

Another well-studied psychotherapy for SP is Interpersonal Psychotherapy (IPT). IPT

is a time-limited psychodynamically based therapy addressing interpersonal difficulties and

interactions here and now. Findings from RCTs comparing CBT and IPT with either

supportive therapy or placebo have been mixed. A Norwegian RCT compared residential IPT

and CBT for 80 patients with SP. They found both therapies to be effective with moderate to

large effect sizes and no differences between the therapies on the primary outcome measures.

The improvement was continued for the whole sample from posttreatment to 1-year follow-up

(Borge et al., 2008).

Psychodynamic psychotherapy for SP has also been studied. Leichsenring and co-

workers have published a treatment manual based on Supportive–Expressive psychodynamic

therapy (2007) and conducted a multicenter RCT of psychodynamic therapy compared with

CBT (2013). Both therapies were efficacious, with differences in favor of CBT. CBT had a

higher remission rate (36%) than psychodynamic therapy (26%) at the end of treatment.

Response rates were 60 and 52%, respectively, comparable to pharmacotherapy. After 6

months follow-up, there were no differences in outcome between the treatment conditions. At

2 years of follow-up, remission rates were almost 40%, and the response rate was 70% for

both treatments (Leichsenring et al., 2014).

It is important to keep in mind that most studies on SP have not assessed concurrent

PDs. Therefore, concurrent AvPD may have influenced the results as a confounding variable.

In most studies of SP, this limitation is not even discussed.

2.3. The relationship between Avoidant Personality Disorder and Social Phobia

The general description of AvPD as a pervasive pattern of social inhibition, feelings of

inadequacy, and hypersensitivity to negative evaluation, starting in early adulthood, may to

some degree also characterize patients with SP, and in particular GSP. However, as a PD,
 23

AvPD should include more profound disturbance of the self and the capacity to relate to other

people. For instance, Millon (1981) suggested that patients with AvPD fear relationships with

other people whereas patients with SP fear social situations.

It is noteworthy that AvPD has primarily been studied in samples of subjects with SP

(Reich, 2014). These studies have documented a quantitative severity continuum with an

increasing gradient of symptoms and psychosocial dysfunction from SSP, via GSP to GSP

with AvPD (Reich, 2014). It is not surprising that the addition of a PD to an anxiety disorder

represents higher levels of symptoms and lower levels of functioning. Still, based on these

findings and apparent similarities in social anxiety and avoidance tendencies, a continuum

hypothesis has been proposed, suggesting that AvPD and SP represent different

conceptualizations of the same disorder, merely differing in degree of severity (Reich, 2014).

However, three review articles evaluating the comparative studies of SP and AvPD have

reached somewhat different conclusions. Reich (2000) concluded that the evidence did not

indicate qualitative differences between AvPD and SP and proposed integrating the disorders

under one concept on Axis I. In contrast, Rettew (2000) and Alden, Laprosa, Taylor, and

Ryder (2002) included in their reviews more studies of personality, PDs, and Axis I disorders

and asserted that more knowledge is needed to clarify possible differences between the

disorders. Bogels et al. (2010) reached a similar conclusion regarding SP in their

recommendations for DSM-5. They stated that sufficient discrepant and discriminating

evidence exists to indicate that it may be overly simplistic to merge AvPD with SP. They

warned that doing so might lead clinicians to overlook serious deficits in normal identity

development and interpersonal relations – cardinal features of PDs.

Most samples of these comparative studies of AvPD and SP comprised patients with

SP with or without AvPD, in which 22–89% of the SP patients had a concurrent AvPD

(Reich, 2014). Moreover, the studies used DSM-III-R, probably creating an artificially high
 24

degree of co-occurrence. However, some recent studies have used DSM-IV and compared

“pure groups” – i.e., a group of persons with AvPD not concurrent with SP (“Pure-AvPD”)

compared with a group of persons with SP without co-occurring AvPD (“Pure-SP”) (Cox,

Stein, & Saeen, 2009; Hummelen et al., 2007; Lampe & Sunderland, 2013), or a Pure-AvPD

group compared with an AvPD+SP group (Ralevski et al., 2005). Two of these are clinical

studies (Hummelen et al., 2007; Ralevski et al., 2005), and two are epidemiological studies

(Cox et al., 2009; Lampe et al., 2013). In a large sample of day-hospitalized patients, most

with PDs, Hummelen et al. (2007) found that 52% of patients with AvPD (total number of

patients with AvPD; n=891) did not have concurrent SP. Also, Ralevski et al. (2005) selected

patients with AvPD (n=325) and found that 69% did not have SP. In a large epidemiological

study, Cox et al. (2009) evaluated a sample from the United States consisting of four groups:

one with pure GSP, one with pure AvPD, one with GSP+AvPD, and one with neither. They

found that 60% of individuals with AvPD (total number of patients with AvPD; n=993) did

not have concurrent GSP. Moreover, in an Australian epidemiologic sample, Lampe and

Sunderland (2015) found that 63% of the people with AvPD (total number of patients with

AvPD: n=185) did not have concurrent SP/GSP. Thus, most patients with AvPD probably do

not meet criteria for SP, an inference that is not in line with the continuum hypothesis and that

contrasts with previous assumptions (Reich, 2000).

Generally, many patients with symptom disorders also have PDs or at least some

dysfunctional personality traits, and most patients with PDs have one or more symptom

disorders. AvPD seems to be typically more associated with SP than with other anxiety

disorders, and SP seems to be more associated with AvPD than with other PDs (Hummelen et

al., 2007). However, in neither case is the relation at all exclusive or close enough to support a

simple severity hypothesis (Hummelen et al., 2007; Skodol et al., 2011). The discussion of

whether AvPD and SP are the same disorder is part of a larger debate of the relationship
 25

between symptom disorders on Axis I and PDs on Axis II (Kreuger, 2005). The discussion

parallels the debate on schizophrenia-like symptoms, affective instability, impulsivity, and

depressive symptoms across Axes I and II. For instance, Borderline PD has for a long period

been proposed to be categorized as a Bipolar spectrum disorder because of similarities of

affective instability and impulsivity (Akiskal et al., 1985; Perugi, Fornaro, & Akiskal, 2011).

Likewise, Schizotype PD is regarded as a Schizophrenia spectrum disorder due to strong

family relationships (Asarnow et al., 2001; Kendler et al., 1993; Kendler, Gruenberg, &

Strauss, 1981) and brain morphological similarities (Buchsbaum et al., 1997). Moreover,

many phenomena and symptoms such as personality dysfunction and attachment problems

show dimensional distributions from low levels in a community sample, with increasing

levels in patients with Axis I disorders and to the most pronounced/troublesome levels in

patients with Axes I and II disorders (Ehrenthal, Dinger, Lamla, Funken, & Schauenburg,

2009; Olsson & Dahl, 2014). For some disorders, differences between the axes could

therefore depend on where we set the bar (Dimaggio et al., 2013).

When Bogels et al. (2010) evaluated SP to give recommendations for DSM-5, they

argued for maintaining the distinction between AvPD and SP and called for more knowledge

to clarify the relationship between the two disorders. So far, studies of the relationship

between AvPD and SP have seldom focused on personality functioning and investigated

variables of personality pathology related to AvPD specifically, or to PDs in general, such as

self-esteem, identity, emotional regulation and avoidance, relational problems, temperament,

childhood experiences/childhood trauma, or attachment organization. In all of these areas, we

lack knowledge about AvPD relative to SP. Also, the significance of having co-occurring SP

and AvPD as compared with “pure AvPD” is still unclear and is insufficiently studied. In the

large clinical study of Ralevski et al. (2005), the addition of SP in patients with AvPD did not

add to the severity of the condition. This finding was partially supported in the
 26

epidemiological study of Cox et al. (2009) regarding co-occurrence of depressive, but not

anxiety disorders. There were no significant differences in the likelihood of being diagnosed

with mood disorders among individuals with GSP+AvPD compared with AvPD alone, but a

higher likelihood of being diagnosed with anxiety disorders. On the other hand, in the

Australian epidemiological study of Lampe and Sunderland (2015), the group of patients with

both AvPD and SP reported more distress and concurrent mental disorders than the groups

with AvPD or SP alone, which did not differ from each other.

Whether AvPD represents a qualitatively distinct category, in the sense of a latent

taxon, is a question that might be approached with taxometric analyses, which should be a

topic for further research (Haslam, 2003). In the meantime, increased knowledge about

personality functioning, temperament, childhood experiences, and attachment strategies could

contribute to a further elaboration of the severity continuum hypothesis currently suggested

for SP and AvPD and elucidate possible differences and similarities between AvPD and SP in

these areas. If AvPD should be classified as a PD in the future, and not merely as a more

severe anxiety disorder, there should be empirically documented differences between AvPD

and SP in personality functioning. Does a diagnosis of AvPD really involve more problems

with identity and relational problems than a diagnosis of SP? Could it be that aspects like

personality functioning and attachment problems better differentiate between AvPD and SP

than severity of anxiety? At present, we have little or no empirical data to answer these

questions.

2.4. Personality functioning

The categorical classifications of PDs in DSM and ICD have important limitations. First,

categorical classifications contradict the general consensus that personality functioning and

PDs are dimensional phenomena (Trull & Widiger, 2013). DSM-IV and ICD-10 have no
 27

measure of severity of personality pathology, other than the Global Assessment of

Functioning scale (GAF). However, severity is the most robust prognostic predictor of current

and prospective dysfunction (Hopwood et al., 2011; Morey, Bender, & Skodol, 2013; Yang,

Coid, & Tyrer, 2010). Furthermore, the general criteria for a PD are non-specific, vague, and

without empirical basis (Livesley, 1998; Hopwood et al., 2011). There is often extensive co-

occurrence of PDs, extreme heterogeneity within diagnosis, and inconsistency of criteria

content, i.e., some criteria are behavioral, others represent personality traits, and some are

cognitive characteristics. Moreover, the relative instability of PD diagnoses documented

during the last decades (Cohen et al., 2005; Grilo et al., 2004a; Gunderson et al., 2011;

Hopwood et al., 2013; Lenzenweger, 2006; Zanarini et al.,2015) is incompatible with the

general definition of PDs as enduring and stable disorders. Furthermore, the diagnostic

thresholds are arbitrary and lack empirical support, and in the existing categorical system,

severity and styles of personality pathology are confounded. As a result, the discriminative

validity of PDs is poor. Finally, it is argued that PDs in DSM-IV have limited predictive

validity and clinical utility (Morey et al., 2007, Morey et al., 2012). For these reasons, the

DSM-5 Personality and Personality Disorder Work Group proposed a new hybrid model of

PDs, with both dimensional and categorical aspects. This new model was intended for the

official classification in DSM-5 but was instead placed in section III, “Emerging Measures

and Models” as an “Alternative Model” of PDs (DSM-5-AMPD; APA, 2013).

The Work Group proposing the AMPD created a dimensional measure of impairment

in personality functioning to address the issue of a PD-specific indicator and of an indicator of

severity in personality pathology. Based on a review of the literature on existing clinician-

administered measures of personality functioning (Bender et al., 2011), the work group

focused on Self and Interpersonal functioning as the two main, reliably measured domains of

personality functioning. The Self and Interpersonal domains are defined by two subdomains
 28

respectively: identity and self direction, and empathy and intimacy. Furthermore, each of these

subdomains comprises three areas of functioning to be assessed (Table 3).

Insert table 3 about here

Little is known about these broad areas of personality functioning in patients with

AvPD and SP. However, self-esteem and interpersonal problems in SP have been studied to

some extent. SP has been associated with self-criticism, low self-esteem, and self-efficacy,

and reduced quality within romantic relationships and friendships as compared with healthy

controls (Cox, Fleet, & Stein, 2004; Iancu, Bodner, & Ben-Zion, 2015; Schreiber, Bohn,

Aderka, Stangier, & Steil, 2012; Cuming & Rapee, 2008; Davila & Beck, 2002; Kachin,

Newman, & Pincus, 2001; Rodebaugh, 2009; Sparrevohn & Rapee, 2008). Except for the

study of Kachin et al. (2001), these studies did not assess co-occurrence of AvPD.

Despite the fact that AvPD is defined with low self-esteem and interpersonal

problems, these topics have been studied only to a small degree. Lynum et al. (2008)

compared self-esteem in treatment-seeking patients with AvPD and/or Borderline PD (BPD)

by use of Index of Self-Esteem (ISE; Hudson, 1982), considering the effect of depression and

concurrent BPD. They found low self-esteem to be associated with AvPD. Bowles, Armitage,

Drabble, and Meyer (2013) studied self-esteem and other-esteem responses to either fully

supportive or less supportive interpersonal feedback in students from London. They found a

significant association for AvPD but not for BPD. Their results indicate that students with

AvPD felt particularly negative about themselves and their close others in situations with

subtle criticism, but not in situations signaling unequivocal support. In a small Chinese

student sample Ye et al. (2011) found that students with AvPD had significantly lower

explicit self-esteem than the healthy controls, as measured by the Rosenberg Self-Esteem
 29

Scale (Rosenberg, 1965; 1979). There were no differences in implicit self-esteem between the

groups.

Regarding interpersonal problems, Rodebaugh, Gianoli, Turkheimer, and Oltmanns

(2010) studied shared variance based on peer and self-report data in a student sample. They

used Multisource Assessment of Personality Pathology (Thomas, Turkheimer, & Oltmanns,

2003) and Inventory of Interpersonal Problems (IIP-64; Horowitz, Alden, Wiggins, & Pincus,

2000). Along with their expectation, they found that AvPD was positively and strongly

correlated with being cold/distant (“it is hard for me to show affection to people”), moderately

correlated with the subscales socially inhibited (“it is hard for me to join in on groups”),

nonassertive (“it is hard for me to be another person’s boss”), and overly accommodating (“it

is hard for me to say no to other people”). There was also a small positive correlation with

self-sacrificing (“I try to please other people too much”) and a negative correlation with

domineering/controlling (“I argue with people too much”). Contrary to their expectation,

AvPD also had a small correlation with the subscale intrusive/needy (“I try to be noticed too

much”). IIP has been developed further to the Circumplex of Interpersonal Problems (CIP;

Alden, Wiggins, & Pincus, 1990; Pedersen, 2002). Wilberg et al. (2009) and Hummelen et al.

(2007) both used CIP in their studies. In these clinical studies, AvPD was associated with

higher levels of interpersonal problems compared with BPD and other PDs (Wilberg et al.,

2009) and compared with SP (Hummelen et al., 2007). Hummelen et al. (2007) compared

patients without overlapping diagnoses and found that both patients with pure AvPD and pure

SP scored high on the subscales socially avoidant (socially inhibited) and nonassertive,

whereas patients with AvPD in addition scored high on cold, exploitable (overly

accommodating), and overly nurturant (self-sacrificing).

Thus, studies of self and interpersonal problems in AvPD have applied a limited range

of instruments, and few studies have conducted direct comparisons of central aspects of
 30

personality functioning in subjects with AvPD and SP. It is therefore an open question

whether patients with AvPD really have more personality pathology or lower personality

functioning than patients with SP. This question is the focus of Paper I.

2.5 Constitutional factors

2.5.1 Heritability

In a Swedish study based on the national patient registers, Isomura and co-workers (2014)

identified 18,399 individuals with SP and 2,673 with AvPD. They found that SP clusters in

families primarily because of genetic factors; relatives at similar genetic distances had similar

risk for SP, despite different degrees of shared environment. Heritability for SP was estimated

to be approximately 56%, and there were no significant sex differences in family patterns.

The risk of AvPD in relatives of SP probands was significantly elevated, even after excluding

individuals with both diagnoses, and decreased with increasing genetic distance. These

authors concluded that SP and AvPD are etiologically related and may represent different

expressions of the same constitutional vulnerability. In a recent longitudinal, population-based

twin study from Norway, Gjerde et al. (2015) found a moderate stability over 10 years and a

heritability estimate of 67% for AvPD. From the same Norwegian Institute of Public Health

Twin Panel, Reichborn-Kjennerud et al. (2007) studied female twins and found heritability

estimates for AvPD and SP to be 37% and 39%, respectively, and that the same genetic

factors influenced AvPD and SP while the environmental factors influencing the two

disorders were uncorrelated and unique to each disorder. Gjerde et al. (2015) and Reichborn-

Kjennerud et al. (2007) used somewhat different methods to estimate heritability. So far,

however, our knowledge of environmental influences associated with the two disorders is

sparse.
 31

2.5.2 Temperament

Risk factors for SP include female gender, a family history of SP, and early childhood shyness

or the temperament trait of behavioral inhibition (Bohlin & Hagekull, 2009; Grant et al.,

2005; Hirshfeld-Becker, 2010; Kessler, Berglund, Demler, Merikangas, & Walters, 2005).

Whether or to what degree behavioral inhibition confers risk for SP in the absence of a family

history of anxiety is still unclear (Hirshfeld-Becker, 2010).

A vulnerable temperament combined with early environmental risk factors is a

suggested etiological factor in the development of both AvPD and SP (Brook & Schmidt,

2008; Joyce et al., 2003; Meyer and Carver, 2000). Shyness has been proposed as a

temperamental trait in both SP and AvPD. However, Prior, Smart, Sanson, and Oberklaid

(2000) found only a modest relation between childhood shyness and adolescent anxiety

disorder in a longitudinal, community study. Most shy children did not develop an anxiety

disorder, and most adolescents with anxiety disorders had not been especially shy (Prior et al.,

2000). Nevertheless, other studies of both epidemiological and clinical samples suggest that

both AvPD and SP are associated with the temperamental factor “behavioral inhibition,”

which is characterized by avoidance of strangers and novelty, shyness, heightened sensitivity,

and anxiety reactivity (Alden, et al., 2002; Bohlin & Hagekull, 2009; Cox, MacPherson, &

Enns, 2005; Meyer, Ajchenbrenner, & Bowles, 2005). Bohlin and Hagekull (2009) followed

85 subjects from a birth cohort for 21 years in the Uppsala longitudinal study. They found that

childhood shyness predicted social anxiety at the age of 21, even when depression was

controlled for. Thus, these disorders seem to have some temperamental dispositions in

common, but temperamental manifestations could still be present in various degrees.

2.6 Childhood experiences

 32

In a review of environmental risk factors for SP, Brook and Schmidt (2008) found studies

of four areas: parenting and family environment, adverse life events, socioeconomic status

and culture, and gender. The authors conclude that “research has successfully correlated

parenting as a small but integral part of the mechanism in developing SAD” and that it points

to an interrelated multi-faceted process of environmental risk and resilience factors in

development of the disorder (Brook & Schmidt, 2008). Knappe et al. (2009) followed a

representative community cohort of 1395 adolescents in Munich over almost 10 years. They

found that parental psychopathology is another risk factor, which interacts with a negative

parental rearing style and may predict the persistence of SP (Knappe, Beesdo-Baum, Fehm,

Lieb, & Wittchen, 2012). PDs were not assessed in this sample.

Kuo, Goldin, Werner, Heimberg, and Gross (2011), in their study of individuals with

GSP, reported more childhood emotional abuse and neglect but not more sexual abuse,

physical abuse, or physical neglect, compared with healthy controls, using the Child Trauma

Questionnaire (CTQ). These results point to less dramatic and more subtle maltreatment as a

possible risk factor in the development of GSP. As for most studies of SP or SAD, co-

morbidity with AvPD was not controlled for. Moreover, like most studies of childhood

trauma, the relative contribution of neglect and abuse was not investigated.

Childhood trauma and parental maltreatment are also well documented as risk factors

for adult PD in general, in both prospective and retrospective studies (Hermandez, Arntz,

Gaviria, Labad, & Gutierrez-Zotes, 2012; Johnson, Cohen, Brown, Smailes, & Bernstein,

1999; Yen et al., 2002; Zhang, Chow, Wang, Dai, & Xiao, 2012). Johnsen et al. (1999) found

that individuals with documented childhood abuse or neglect were four times as likely as

those who were not abused or neglected to be diagnosed with PDs during early adulthood.

Childhood emotional neglect was associated with increased risk of several PDs, including

AvPD (Johnson, Smailes, Cohen, Brown, & Bernstein, 2000).

 33

So far, few studies have focused specifically on AvPD and childhood experiences.

However, the large clinical study from the United States Rettew et al. (2003), found that

patients with AvPD reported more physical and emotional abuse during childhood compared

with patients with major depression. The association fell, though, when concurrent diagnoses

of PTSD and BPD were accounted for. In a large outpatient sample in Shanghai, self-reported

experience of childhood emotional neglect was associated with adult cluster C PDs (Avoidant,

Dependent, and Obsessive–Compulsive PD) (Zhang et al., 2012). Joyce et al. (2003) found

that self-reported childhood neglect predicted AvPD in a sample of depressed outpatients.

Moreover, in an early, small retrospective study, Arbel and Stravynski (1991) found that the

main features differentiating adult AvPD patients from healthy controls were the perception

of a discouraging home climate with less parental demonstration of love and pride in the

child, and a perception of their parents as shaming, guilt-engendering, and intolerant.

Abuse refers to maltreatment, harmful behavior, and non-accidental injury from an

adult person directed toward the child whereas neglect refers to the failure of caretakers to

provide a child’s basic psychological or physical needs (Bernstein & Fink, 1998). Generally,

childhood neglect has received less empirical attention than childhood abuse (Carr, Martins,

Stingel, Lemgruber, & Juruena, 2013). In clinical settings, the experience of neglect in

childhood may be overshadowed by dramatic histories of maltreatment and abuse. However,

parental abuse and neglect can co-occur in dysfunctional families, making it difficult to

disentangle specific consequences of the various types of maltreatment that the child may

suffer (Nederlof, Van der Ham, Dingemans, & Oei, 2010). At present, little is known about

the unique contribution of neglect to adult psychopathology more generally, either to AvPD

or SP.

Parental behavior has also been studied with the Parental Bonding Instrument (PBI)

(Parker, Tupling, & Brown, 1979), which aims to collect relevant retrospective information
 34

about childhood experiences. A combination of low scores on the two subscales care and

control is called the neglectful parenting pattern, which was found to be the dominating

pattern in a small sample of patients with AvPD (Stravynski, Elie, & Franche, 1989).

However, when Joyce et al. (2003) found neglect to be associated with AvPD, they

operationalized neglect as low scores on the care dimension only. A combination of low

scores on the care and high scores on the control subscales is called the cold control pattern,

which has been associated with many kinds of adult psychopathology (Nordahl & Stiles,

1997; Reti et al., 2002; Torgersen & Alnaes, 1992). The cold control pattern might also be

among the risk factors for SP (Brook & Schmidt, 2008; Bogels, Stevens, & Majdandzic,

2011; Bogels et al., 2010).

Maltreatment probably interacts with temperamental factors to influence personality

development and risk of psychiatric symptoms (Joyce et al., 2003). Rothbart and Derryberry

(2002) defined temperament as constitutionally based individual differences in emotional,

motor, and attentional reactivity and regulation. Temperament is influenced by experience, in

turn influences experience, and is gradually transformed and integrated into our adult

personality (Rothbart, Ahadi, & Evans, 2000).

Taken together, AvPD and SP seem to be influenced by the same genetic

vulnerability, probably including shyness, while the environmental factors shaping the two

could be unique to each disorder. Some studies indicate that both AvPD and SP are associated

with various types of childhood maltreatment. Most notable, however, no studies have made a

direct comparison of childhood environmental factors between the disorders, and little is

known about the unique contribution of childhood neglect to adult psychopathology, relative

to childhood abuse. We wanted to compare self-reported childhood experiences for patients

with AvPD and SP to shed further light on the relationship between the two disorders.
 35

Additionally, we wanted to examine the relative contribution of abuse and neglect, also taking

temperament characteristics into account. These are the topics of paper II.

2.7 Attachment

The capacity to establish and maintain mutual and nourishing relationships is a central

aspect of personality functioning and is important for the well-being of humans. Both AvPD

and SP are associated with elevated levels of interpersonal problems (Cuming & Rapee, 2010;

Davila & Beck, 2002; Eikenaes et al., 2006; Hummelen et al., 2007; Rodebaugh et al., 2010).

Individuals with these disorders are less likely to develop romantic relationships or to be

married (Hummelen et al., 2007; Sparrevohn & Rapee, 2009; Taylor et al., 2004), and some

studies have found lower levels of social support and intimacy and less emotional expression

and self-disclosure within close relationships for subjects with both disorders (Davila & Beck,

2002; Marques et al., 2012; Sparrevohn & Rapee, 2009; Taylor, et al., 2004). In a study of

patients with AvPD and SP, without overlapping diagnoses, those with AvPD less often lived

with a partner and had a close person committed to them; in addition, they experienced more

interpersonal distress and a broader array of interpersonal problems compared with patients

with SP (Hummelen et al., 2007). In a large sample of treatment-seeking patients with GSP,

Marques et al. (2012) found that the presence of more AvPD criteria was associated with a

higher perceived risk of intimacy, lower social support, and more emotional guardedness.

Such indications of intimacy problems suggest that attachment difficulties could be significant

for AvPD and SP and probably more pronounced for AvPD. Whereas SP is defined as fear of

humiliation and embarrassment in response to unfamiliar people or expectations of critical

scrutiny by others, AvPD is defined in more explicit attachment-relevant terms, as follows: a

negative sense of self, restraint within intimate relationships, including sexual intimacy, with

a fear of rejection, criticism, and humiliation (DSM-IV, DSM-5) (APA, 1994, 2013). Thus,
 36

AvPD and SP could be associated with different levels or types of problems in close

relationships, reflecting underlying differences in attachment.

2.7.1 Adult attachment

Our understanding of adult attachment is based on the attachment theory of John Bowlby

(1969, 1973, 1980, 1988). Bowlby claimed that human attachment plays a “vital role … from

the cradle to the grave” (1969, p. 2008). He refers to the close emotional bond between child

and caregivers, with the parent as a secure base for the child, promoting the child’s

development of affect-regulation, autonomy, and confidence in self and others. Based on

experiences in early attachment relationships, the child develops mental representations of

self and others and self in relation to others, the so-called internal working models. These

affective–cognitive representations mirror the behavioral patterns of attachment, which are

assumed to play a crucial role in the development of identity and interpersonal functioning.

Thus, the organization of adult attachment is rooted in such internal working models, which

later influences the capacity to establish mutually nurturing relationships as an adult (Bowlby,

1969; Hazan & Shaver, 1994).

Adult romantic attachment differs from parent–child bonds in several ways, including

reciprocity of attachment, serving as a secure base for each other, and sexual mating. Adult

attachment has been studied in two research traditions that apply somewhat different

methodology. The developmental approach (Ainsworth, Blehar, Waters, & Wall, 1978) is

primarily based on the Adult Attachment Interview (AAI) (George, Kaplan, & Main, 1985),

examining the adult’s state of mind regarding attachment through current narratives of their

childhood experiences with caregivers. In the social attachment approach, attachment is

mainly assessed by self-report questionnaires that more directly assess qualities in current

close relationships (Crowell, Fraley, & Shaver, 2008; Hazan & Shaver, 1994). Self-report of
 37

adult attachment is less time-consuming, less expensive, and easier to administer compared

with interviews like AAI. On the other hand, attachment is partly an unconscious process that

could more easily be uncovered by the AAI (Hesse, 2008) whereas self-reports could be

biased, for example, by social desirability or self-deception. One of the many self-report

instruments of adult attachment is the Experience in Close Relationships inventory (ECR)

(Brennan, Clark, & Shaver, 1998) based on the social attachment approach. ECR is a widely

used, short, and highly relevant questionnaire, focusing on current close relationships.

2.7.2 Attachment studies in AvPD

Studies of attachment in subjects with AvPD are scarce (Tiliopoulos & Jiang, 2012).

However, a few studies have investigated the attachment aspects of AvPD using specific

attachment instruments. Riggs et al. (2007) studied attachment, personality, and

psychopathology among 80 patients hospitalized for treatment of trauma-related disorders

using the ECR. They found that scores on the AvPD scale measured by self-report (Millon

Clinical Multiaxial Inventory; Millon & Davis, 1997) were associated with a Fearful

attachment style. Fossati et al. (2003) used the Attachment Style Questionnaire in a large

sample of patients with PDs. They found that discomfort with closeness and a lack of

confidence in attachment relationships, with close resemblance to high attachment anxiety

and avoidance, correlated with AvPDs. The Structured Clinical Interview for DSM-IV PDs

(SCID-II; First, Gibbon, Spitzer, Williams, & Benjamin, 1997) was used for assessing PDs. In

a large clinical study, Nakash-Eisikovits, Dutra, and Westen (2002) used a clinician-report

attachment questionnaire and found that Disorganized/Unresolved attachment was correlated

with DSM-IV AvPD criteria. A study of self-reported attachment in a student sample found

similar results (Meyer, Pilkonis, & Beevers, 2004). Finally, in a study using the AAI, the 12
 38

patients with AvPD displayed an apparently Dismissing attachment that concealed a more

Ambivalent/Preoccupied pattern (Rindal, 2000). Sheldon and West (1990) did not apply any

specific attachment instrument but studied self-reports from 47 patients with AvPD. They

found that desire for but fear of an attachment relationship was more characteristic of these

patients than a low level of social skills. These results are quite consistent and indicate both

high attachment anxiety and avoidance (see 2.8) in AvPD.

2.7.3 Attachment studies in SP

A review of environmental risk factors in SP concluded that studies consistently demonstrate

an association between insecure attachment and the development of anxiety without any

specificity in this relation (Brook & Schmidt, 2008). Yet, in prospective studies applying

different methodologies, researchers have found that an Anxious–Ambivalent attachment

pattern in childhood predicts SP or social withdrawal in adolescents (Bar-Haim, Dan, Eshel,

& Sagi-Schwartz, 2007; Warren, Huston, Egeland, & Sroufe, 1997). In a study of 154 high-

risk women, Bifulco et al. (2006) found that SP was associated with a Fearful attachment

style as assessed by the Attachment Style Interview (Bifulco, Moran, Ball, & Bernazzani,

2002). However, concurrent AvPD was not assessed in these studies. In two large samples of

SP patients, Eng, Heimberg, Hart, Schneier, and Liebowitz (2001) used the Revised Adult

Attachment Scale (Collins and Read, 1990; Collins, 1996), assessing the three attachment

styles described by Hazan and Shaver (1987) (Secure, Avoidant, and Anxious–Ambivalent) in

the context of romantic relationships. By cluster analyses, they found that patients with SP

were characterized either by a secure or an anxious–ambivalent attachment style. The

Anxious–ambivalent group was more impaired and had a higher rate of patients with co-

occurring AvPD, as measured by self-report.

 39

Taken together, few studies have examined attachment styles in subjects with AvPD

and SP, particularly in clinical populations. The existing studies suggest that both diagnoses

may be associated with attachment problems, but research on SP has seldom specified the

degree of co-morbidity with AvPD. Moreover, most studies have not assessed the rates of

GSP, which could be more similar to AvPD regarding problems in close relationships than the

more circumscribed SP (Kachin et al., 2001; Perugi et al., 2001). Thus, we have insufficient

knowledge regarding attachment problems related to AvPD and SP. In paper IV, we studied

attachment styles to further elucidate the similarities and differences between the two

disorders. To our knowledge, no previous study has compared attachment problems between

AvPD and SP.

2.8. Experience in Close Relationship inventory (ECR). Psychometric properties

Several questionnaires have been developed to assess adult attachment. Among them

are Brennan et al.’s (1998) ECR, Collins and Read’s (1990) Adult Attachment Scales, Griffin

and Bartholomew’s (1994) Relationship Styles Questionnaire, and Simpson’s (1990)

Attachment Style Measure. In a study comparing these questionnaires, Fraley, Waller, &

Brennan (2000) found the ECR to reveal the best psychometric properties. Furthermore,

Brennan et al. (1998) reported a high internal consistency of its two subscales of Anxiety and

Avoidance, with Cronbach’s alpha coefficients (Cronbach, 1951) of 0.91 and 0.94,

respectively. These high levels have also been confirmed in other studies (Lopez & Gormley,

2002; Olssøn, Sørebø, & Dahl, 2010; Vogel & Wei, 2005).

Both theoretical models of adult attachment (Ainsworth et al., 1978; Bartholomew,

1990; Bartholomew & Horowitz, 1991; Mikulincer, Shaver, & Pereg, 2003) and factor

analyses of ECR (Brennan et al., 1998; Ehrenthal, et al., 2009; Olsson et al., 2010; Wei,

Russell, Mallinckrodt, & Vogel, 2007) have identified two underlying dimensions of adult
 40

attachment: Anxiety and Avoidance. High attachment anxiety involves a fear of interpersonal

rejection or abandonment, an excessive need for approval from others, and distress when

one’s partner is unavailable or unresponsive. In contrast, high attachment avoidance involves

fear of interpersonal dependence, preference for self-reliance, and reluctance to self-disclose

(Wei et al., 2007).

According to Bartholomew (1990; Bartholomew & Horowitz, 1991), four categories

of adult attachment styles can be derived by these two dimensions, including one Secure (low

anxiety/low avoidance, with a positive model of self and other) and three anxious or insecure

styles: Fearful (high anxiety/high avoidance, with a negative model of self and other),

Dismissing (low anxiety/high avoidance), and Preoccupied (high anxiety/low avoidance). The

labels of these attachment styles seems semantically parallel to the classification of

attachment patterns described by George et al. (1984) based on AAI: Secure, Dismissing,

Preoccupied, and Unresolved/Disorganized, in addition to a Cannot classify pattern.

However, there is a weak concordance between attachment security assessed by self-report

and AAI (Riggs et al., 2007; Roisman et al., 2007; Treboux, Crowell, & Waters, 2004),

probably because these measures are tapping different phenomena or aspects of adult

attachment.

At present, the ECR is perhaps the most frequently used questionnaire for the

assessment of adult attachment in intimate relationships. However, our current knowledge of

its psychometric properties is mainly derived from student and community samples, which are

associated with high rates of secure attachment (Lopez, Mitchell, & Gormley, 2002; Olssøn et

al., 2010; Wei, Mallinckrodt, Larson, & Zakalik, 2005; Wei, Russell, Mallinckrodt, &

Zakalik, 2004). Considering the extensive application of ECR in clinical research and settings,

it is important to further investigate its psychometric properties in clinical samples, especially

in samples with PDs that are known to have high rates of insecure attachment styles
 41

(Crawford et al., 2006; Lorenzini & Fonagy, 2013; Olssøn & Dahl, 2014; Westen, Nakash,

Thomas, & Bradley, 2006).

The ECR comprises 36 items, 18 of which address Anxiety and 18 that address

Avoidance related to a person’s intimate relationships. Traditionally, when as many as 18

indicators are used to operationalize a homogeneous latent construct, the internal consistency,

as assessed by Cronbach’s alpha, will be increased just by the number of items alone and

seldom will be less than 0.80. Moreover, it has yet to be seen in social science that the

variance in 18 items is accounted for by just one single latent variable, unless the items are

shown to be paraphrases or repetitions of each other, what Cattell (1957) called bloated

specifics. Generally, the variance of such a high amount of indicators is usually accounted for

by two or more somewhat different aspects of the higher order latent construct. Instruments

designed in this way can often be shortened with success, as well as with improved validity of

the inferences that are made from their scores.

Accordingly, two different 12-item versions have been derived from ECR. In four

different studies, Wei et al. (2007) derived a 12-item version assessing Avoidance and Anxiety

and confirmed its psychometric properties, validity, and short-term stability (ECR-S). Wei et

al. (2007) based their findings on different student samples in the United States. In a

Norwegian study, Olssøn and co-workers (2010) used a randomly selected community sample

of 437 persons to investigate the psychometric properties of the 36-item version and also to

identify a short version of 12 items (ECR-N12). From a confirmatory factor analysis, they

found a somewhat questionable fit to a two factor model of Avoidance and Anxiety in the 36-

item version but failed to confirm good fit for two factors from the 12-item version of Wei et

al. (2007). Therefore, they went on to search for an alternative 12-item short version within

their own sample. Their new proposed short form showed good fit to a two factor model
 42

(Olssøn et al., 2010); however, their version shared only four items with the ECR-S of Wei et

al. (2007).

Another line of research is to investigate whether the instrument contains sub-factors

that account for different aspects of the two main dimensions Anxiety and Avoidance. By

confirmatory factor analyses with varying numbers of factors, Olssøn et al. (2010) found good

fit for a five factor model of ECR in their community sample. Their findings suggest that

Avoidance and Anxiety may be second-order dimensions covering two and three sub-factors,

respectively. Thus, ECR may contain information that could give a more nuanced picture of

attachment problems in subjects with various psychiatric disorders. However, their findings

need replication in clinical samples. In paper III, we investigated the psychometrics of ECR in

a large sample of patients with PDs.

3 AIMS AND HYPOTHESES

3.1 Main aims

The thesis aimed to explore differences and similarities in developmental and

psychopathological aspects of AvPD and SP to provide a more thorough understanding of the

psychopathology of AvPD and the relationship between AvPD and SP. We compared

symptoms, personality pathology and functioning, temperament, childhood

experiences/trauma, and attachment styles in patients AvPD and SP. We also aimed to

investigate the psychometric properties of the Norwegian version of ECR and its two short-

forms in a sample of patients with mainly PDs.

We hope to increase knowledge of AvPD and thereby contribute to a basis on which

development of more efficient treatment programs for AvPD may be established. Thus, we

hope to stimulate more interest and research in AvPD and in the longer run indirectly

contribute to improvement in the prognosis of AvPD.

 43

3.2 Specific aims, hypotheses, and research questions

Paper I: We expected that compared with the Pure-SP group, patients in the Pure-

AvPD group and the AvPD+SP group would report more symptom distress, have more Axis I

pathology, and manifest a lower level of work and social functioning. We also expected that

patients in the Pure-AvPD group and the AvPD+SP groups would have more fulfilled PD

criteria and report more severe personality dysfunction in the self and relational domains of

personality, particularly in terms of lower self-esteem, more unstable self-representations, less

experience of enjoyment, and more deficient relational functioning and interpersonal

problems. Moreover, because both the Pure-AvPD group and the AvPD+SP group involve

AvPD (i.e., personality pathology), we expected that these two groups would be more similar

to each other than either would be to the Pure-SP group regarding psychosocial and

personality functioning. Finally, we expected that in multivariate analyses, a diagnosis of

AvPD would contribute to the explained variance in self-pathology and relational dysfunction

independent of the number of co-occurring symptom disorders, other PDs, and the presence of

SP.

Paper II: Based on previous research, we 1) expected that patients in the AvPD group

would report more severe childhood maltreatment than patients in the SP group as assessed by

CTQ; 2) we further explored the relationship between the diagnostic groups and childhood

maltreatment when taking into account the presence of different trauma; 3) we expected that

the AvPD group more often would report a neglectful parenting style compared with the SP

group, measured by PBI, whereas the groups would not differ in rates of a cold control

parenting style; and finally, 4) we hypothesized that differences in environmental factors

would remain significant when controlling for temperament.

 44

Paper III: First, we wanted to investigate the two factor model of the ECR. Second,

we wanted to investigate the psychometric properties of the two proposed short forms from

Wei et al. (2007) and Olssøn et al. (2010), and finally, we wanted to explore the factor

structure of ECR in full, in search of potential sub-factors.

Paper IV: We applied a partly hypothesis-testing, partly explorative approach. First,

we hypothesized that the AvPD group would have higher scores on both the Anxiety and

Avoidance scales compared with the SP group. Next, we compared the levels of the five sub-

factors of ECR in the two diagnostic groups and expected that the AvPD group would have

higher scores on Anxiety for abandonment compared with the SP group. We also investigated

whether the five sub-factors contributed to the explained variance in the number of AvPD

criteria over and above number of symptom disorders, SP, and number of other PD criteria.

Finally, we compared the distribution of the four categories of attachment styles in the two

diagnostic groups and expected the Fearful attachment style to be more frequent among

patients with AvPD compared with the SP group.

4 METHODS

4.1. Settings, design, and samples

Papers I, II, and IV are based on a cross-sectional multi-site study conducted by

Vestfold Hospital Trust, and included 91 adult patients with AvPD and/or SP. Sixty-six of the

ninety-one patients were recruited by their current therapists from seven treatment centers

specialized in treating PDs or anxiety disorders. The Units of group therapy in Drammen,

Skien, Sandefjord, Tønsberg, and Holmestrand are specialized in treating PDs whereas the

anxiety clinics on Gaustad and Modum-Bad are specialized in treating SP. Recruitment of

these patients was based on the therapist’s diagnostic screening and evaluation whereas
 45

inclusion was based on subsequent research interviews. Patients were recruited regardless of

time in therapy. In total, 72 patients were recruited; 6 of them were excluded because the

research interviews revealed diagnoses of alcohol dependency (n=2), adult attention deficit-

hyperactivity disorder (ADHD) (n=2), or Borderline PD (n=1), which were exclusion criteria,

and one patient dropped out before completing the interviews.

Of the 91 included patients, 25 were selected from baseline data of the Ullevål

Personality Project (UPP), a treatment study for patients with PDs conducted by the

Department of Personality Psychiatry, Oslo University Hospital (Arnevik et al., 2009a). For

all 91 patients, exclusion criteria were cluster A or B PDs, current alcohol or substance

dependency, psychotic disorders, bipolar I disorder, adult ADHD, pervasive developmental

disorders (e.g., Asperger’s syndrome), organic syndromes, and homelessness. Study

participation was voluntary, and all patients gave informed written consent before inclusion.

The study was approved by the Norwegian Social Science Data Service and the Regional

Committee for Medical Research Ethics.

Paper III is a cross-sectional study based on ECR data from a sample of 495 patients

consecutively admitted to Department of Personality Psychiatry, Oslo University Hospital, in

Norway between 2004 and 2013. All patients gave their written, informed consent to

participation in the research, and data were registered in an anonymous central database. The

State Data Inspectorate and the Regional Committee for Medical Research and Ethics

approved the procedures.

4.2 Assessments by interviews: Axis I and Axis II diagnoses

In papers I, II, and IV, Axis I diagnoses were based on the Mini International

Neuropsychiatric Interview for Axis I diagnoses (M.I.N.I.; Sheehan et al., 1994). The

Structured Clinical Interview for the 4th edition of the Diagnostic and Statistical Manual of
 46

Mental Disorders (DSM-IV) was used to assess PDs on Axis II (SCID-II; First et al., 1997).

Trained and experienced clinicians conducted the interviews. All patients with SP without co-

occurring AvPD were asked to describe examples of SP-related problems from their lives,

which were used along with other information to evaluate whether they had simple or

generalized SP.

We conducted a reliability test of the diagnostic assessments of the 66 patients from

the different treatment centers mentioned above. All diagnostic interviews were audiotaped.

An independent, blind, and experienced psychiatrist rated the interviews of 26 randomly

selected patients. Although there was 85% agreement regarding the presence or absence of SP

(21 of 22 patients diagnosed with SP), there were too few patients without SP among the 26

patients to compute kappa for SP. Kappa for AvPD was 0.76. The intraclass correlation (ICC

2.1) was 0.86 (95% CI: 0.71–0.93) for the number of Avoidant PD criteria and 0.89 (95% CI:

0.75–0.95) for the total number of PD criteria, indicating satisfactory diagnostic reliability.

Diagnostic reliability of the 25 patients from the UPP was tested in the same way as

described above. In UPP, the kappa values were 0.92 for SP and 0.75 for AvPD, respectively;

ICC (ICC 3.2) on number of fulfilled SCID-II criteria was 0.95 (95% CI: 0.73–1.00) and was

somewhat lower for other symptom disorders and other PDs. Thus, diagnostic reliability was

not excellent but acceptable.

Also in paper III, all patients were diagnosed according to the DSM-IV by use of the

M.I.N.I. for symptom disorders and the SCID-II for PDs. The reliability was not investigated;

however, the staff in the unit were thoroughly trained in diagnostic procedures, and they were

instructed to follow the LEAD procedure (Longitudinal, Expert, All-Data: Spitzer, 1983;

Pedersen et al., 2013). With this procedure, tentative diagnoses were given at admission on

the basis of referral letters, self-reported history and complaints, several assessment

interviews, SCID-II, and M.I.N.I.

 47

4.3. Assessments by self-report instruments

4.3.1. Personality functioning

(Mal) Adaptive personality functioning. The patients completed The Severity Indices

of Personality (SIPP-118; Andrea, 2007), which measures the core components of (mal)

adaptive personality functioning. The respondents were asked to think about the past 3

months and to describe the extent to which they agreed with statements like “It is hard for me

to feel loved by people I have become close to” and “I often feel that I am not as worthy as

other people.” The response categories ranged from 1–4, representing “fully disagree,” “partly

disagree,” “partly agree,” or “fully agree.” A higher score indicates better personality

functioning. The covered 16 facets (stable self-image, self-respect, enjoyment, enduring

relationships, intimacy, feeling recognized, self-reflexive functioning, emotion regulation,

aggression regulation, frustration tolerance, effortful control, purposefulness, respect,

cooperation, trustworthiness, and responsible industry) are clustered into five higher order

domains: identity integration, relational capacities, self-control, social concordance, and

responsibility (Andrea, 2007; Arnevik, Wilberg, Monsen, Andrea, & Karterud, 2009).

Previous studies indicate that SIPP-118 shows good concurrent and discriminant validity,

test–retest reliability (Andrea, 2007), and cross-national validity (Arnevik et al., 2009b).

Self-esteem. We used the ISE (Hudson, 1982; Tempe, 1992), a 25-item questionnaire

measuring the severity of a subject’s self-esteem problems. Respondents were asked to rate

statements like “I feel that people would not like me if they really knew me well” on a Likert

scale ranging from 1 “None of the time” to 7 “All of the time.” Some items are reversed.

Scores range from 0–100; a score of 0 indicates that the subject has none of the attributes, and

100 represents the highest possible distress level. The scale has two clinical cut-off scores:

scores above 30 indicate clinically significant self-esteem problems, and scores above 70
 48

indicate constant severe stress. The Norwegian ISE scale has been shown to have good

internal consistency in a PD sample (Lynum, et al., 2008).

Interpersonal problems. To assess interpersonal problems, we used the CIP, a 0-to-4

Likert scale self-report questionnaire (Alden et al., 1990; Pedersen, 2002). The CIP is a 48-

item version of Alden et al.’s IIP-C. It comprises eight subscales (i.e., domineering,

vindictive, cold, socially avoidant, non-assertive, exploitive, overly nurturant, and intrusive),

an index of mistrust, and a sum score (CIP sum) that correlates 0.99 with the sum score

obtained from Alden’s IIP-C (Pedersen, 2002). A higher score indicates more severe

interpersonal problems.

4.3.2 Symptoms. We applied the Beck Depression Inventory (BDI; Beck et al., 1961), a 21-

item self-report inventory that measures presence and degree of depression. The sum score is

an index of depression ranging from 0–63. Sum scores between 19 and 29 indicate moderate

depression while scores of 30 and above indicate severe depression. To measure general

symptomatic distress, we used the revised Symptom Check List (SCL-90-R; Derogatis, 1994),

a self-report questionnaire with a 0-to-4 Likert scale covering the major symptoms of psychic

distress summarized in a Global Severity Index (GSI). A higher score indicates more

symptomatic distress.

4.3.3 Work and social functioning. The patients completed the Work and Social Adjustment

Scale (WSAS; Mundt, Marks, Shear, & Greist, 2002), a simple 5-item measure of general

social impairment that has demonstrated good validity and reliability (Mataix-Cols et al.,

2005). Disability in work, home management, social and private leisure, and interpersonal

relations are rated on a 9-point Likert scale from 0 to 8, with higher scores indicating greater

disability. The sum score ranges from 0–40.

 49

4.3.4 Quality of life. The patients were asked to rate their present quality of life on a scale

from 1–10, where 10 represents “as good as possible” and 1 represents “as bad as possible.”

4.3.5 Childhood experiences

Childhood trauma was assessed using the CTQ, a 44-item retrospective self-report

inventory that provides brief screening for histories of abuse and neglect and has shown good

reliability and validity (Bernstein et al., 1994; Bernstein, Ahluvalia, Pogge, & Handelsman,

1997). Items are scored on a 5-point Likert scale from 1 (never true) to 5 (very often true).

Items scored are summed on five different subscales: emotional, physical, and sexual abuse,

and physical and emotional neglect. Emotional abuse refers to verbal assaults on a child’s

sense of worth or well-being, or any humiliating, demeaning, or threatening behavior.

Physical abuse includes descriptions of bodily assaults that pose a risk of or result in injury.

Sexual abuse describes sexual contact or conduct. Emotional neglect refers to lack of love,

encouragement, belonging, and support. Physical neglect refers to lack of food, shelter,

safety, supervision, and health care. It is not unusual to underreport childhood trauma (Hardt

& Rutter, 2004; Widom & Shepard, 1996; Widom & Morris, 1997), and the CTQ therefore

includes a 3-item denial/minimization scale to detect false-negative trauma reports. The raw

scores of the five CTQ subscales are not comparable and have different cut-off thresholds.

Raw scores were therefore converted into classifications of four levels of severity based on

validation studies in normal and psychopathological samples (Bernstein & Fink, 1998):

“absent to minimal” (1), “low to moderate” (2), “moderate to severe” (3), and “severe to

extreme” (4). We used these four levels of severity to harmonize the subscales. In this way,

we were able to compute a composite neglect score based on the average classification of
 50

severity (1–4) of emotional and physical neglect. Likewise, we computed a composite abuse

score from the three abuse subscales: emotional abuse, physical abuse, and sexual abuse.

Perceived parental behavior was assessed by the 25-item PBI (Parker et al., 1979).

The self-report questionnaire comprises 25 items that are scored on a 5-point Likert scale

from 1 (very likely) to 5 (very unlikely), based on perceived parental behavior before age 16

years. Usually two subscales are computed for each parental figure: care/affection and

overprotection/control. The combination of the two subscales generates four parental styles:

optimal bonding (high care, low overprotection); affectionate constraint (high care, high

overprotection); affectionless control, also called cold control (low care, high overprotection);

and neglectful parenting (low care, low overprotection). Cut-off scores for high and low care

and overprotection were computed based on normative data (Parker, 1989). The respective

cut-off scores are 27 and 24 for maternal and paternal care, and 13.5 and 12.5 for maternal

and paternal control. We used these cut-offs to compute the four patterns.

4.3.7 Temperament. The short form of the Adult Temperament Questionnaire (ATQ)

(Rothbart et al., 2000) was used to assess temperament. The ATQ is a self-report

questionnaire that consists of 77 items rated on a 7-point Likert scale and includes four factor

scales: effortful control, negative affect, extraversion, and orienting sensitivity. Good internal

consistency was reported in a student sample (Posner & Rothbart, 2000). The same level of

internal consistency was observed for the Norwegian version of the ATQ in the UPP sample,

(Urnes et al., unpublished data).

4.3.8 Attachment

Attachment style was assessed by the ECR, a 36-item self-report of adult attachment

developed by Brennan, Clark, and Shaver (1998), which has been documented as highly
 51

reliable and valid (Wei et al., 2007). The translation to Norwegian was created in accordance

with the guidelines of Hambleton (2005) by a group of clinicians and researchers under the

oversight of our colleague Øyvind Urnes, MD, at the Department of Personality

Psychopathology, Oslo University Hospital. The final translation was retranslated back to

English by a bilingual translator and then compared with the original questionnaire. By factor

analyses, Brennan et al. (1988) identified two relatively orthogonal dimensions, 18 items

each, addressing attachment Anxiety, e.g., item 2, “I worry about being abandoned”; and

attachment Avoidance, e.g., item 13, “I prefer not to show how I feel deep down.” The factor

structure has been replicated in different samples (Ehrenthal et al., 2007; Olssøn & Dahl,

2014; Wei et al., 2007), but not yet in clinical samples of PDs. The patients rate how well

each statement describes their typical feelings in close relationships by a score on a 7-point

Likert scale from 1 (not at all) to 7 (very much). Higher scores indicate more attachment-

related anxiety or avoidance. Combining the two main dimensions Anxiety and Avoidance

defines four categories of attachment styles: Secure (low anxiety/low avoidance) and three

insecure, i.e., Dismissing (low anxiety/high avoidance), Preoccupied (high anxiety/low

avoidance), and Fearful (high anxiety/high avoidance).

4.4 Statistics

Paper I: Differences in categorical and continuous variables among the three

diagnostic groups were tested by Chi-squared tests and one-way analyses of variance

(ANOVAs) with least-significance difference post hoc tests for pair-wise comparisons. For

effect size of the between-group differences, Cohen’s d and Eta² were computed. To

investigate whether the difference in personality functioning was specifically connected to

AvPD and not entirely explained by other psychopathology, we made a series of multiple

regression analyses. The personality variables that differed between the groups were entered
 52

as dependent variables, controlling in the following for (a) number of symptom disorders

other than SP, (b) number of PDs other than AvPD, and (c) a diagnosis of SP. AvPD was

entered as the last predictor.

Papers II and IV: Background demographic and clinical variables of the two

diagnostic groups were analyzed using t-tests and Chi-squared tests for continuous and

categorical variables, respectively. We compared the groups by applying ANOVA for the

continuous variables of the CTQ, ATQ, and PBI. Because skewed distributions of the separate

abuse subscales of the CTQ precluded the use of parametric methods, the Mann–Whitney test

was used. To analyze the unique contribution of the variables showing significant group

differences in the ANOVAs, follow-up covariance analyses (ANCOVAs) were performed

controlling for the effects of the possible confounding variables. We used Eta² and r² as

measures of effect size for the normal and the skewed distributed data, respectively.

For the subscale Avoidance of closeness, a high kurtosis value in the AvPD group

prohibited the use of parametric methods, and the Mann–Whitney test was used. For the same

reason, we used the Avoidance score instead of the two sub-scales of avoidance in the

regression analysis. To test the association between AvPD and the attachment sub-factors,

multiple linear regression analysis was applied with the number of fulfilled AvPD criteria as

the dependent variable and ECR scales as independent variables. The first four blocks were

demographic and clinical control variables and the next four relate to the attachment variables

of interest.

Paper III: Internal consistency was estimated by Cronbach’s alpha (Cronbach, 1951),

group differences were analyzed by independent samples t-test (two-sided), and linear

relationships between variables were estimated by Pearson’s Product Moment Correlations.

Exploratory factor analysis was conducted by Principal Axis Factoring (PAF) with Promax

rotation. Effect sizes of gender differences were estimated by Hedge’s g (Hedges, 1981).
 53

Confirmatory factor analysis (CFA) was conducted with Mplus 7.11 (Muthén & Muthén,

2012) with estimations based on the Maximum Likelihood Mean adjusted function. This

mean-adjusted Chi-squared test statistic, also referred to as the Satorra–Bentler Chi-square

(Satorra & Bentler, 2001), is also robust to non-normality. To evaluate the CFA models,

goodness of fit was estimated by Root Mean Square Error of Approximation (RMSEA;

Steiger, 1990), the Non-Normed Fit Index (Bentler & Bonett, 1980), also called the Tucker

Lewis index (TLI; Tucker & Lewis, 1973), the Comparative Fit Index (CFI; Bentler, 1980),

and the Standardized Root Mean Square Residual (SRMR; Hu & Bentler, 1999).

In general: Cohens d was computed by means (M) and pooled standard deviations (ϭ):

d = M1 - M2 / pooled where pooled =√[( 12+  22) / 2]

According to Cohen (1988), effect sizes <0.20 indicate no effect, 0.20–0.49 a small effect,

0.50–0.79 a moderate effect, and ≥0.80 a large effect. The significance level was set at p<0.05

(two-tailed). The statistical analyses were performed by use of the Statistical Package for

Social Science (SPSS) Version 16.0 in papers I, II, and IV and Version 19.0 (IBM, 2007 and

2010) in paper III.

4.5 Participants

The sample in papers I, II, and IV comprised 91 patients, of whom 15 (16.5%) were

diagnosed with AVPD without SP, 56 (61.5%) had both AVPD and SP, and 20 (22%) had SP

without AVPD. Mean age was 37.6 years (SD=10.2), 65% were female, and 44% married or

cohabiting, and they had an average of 4 years of education after junior secondary school

(SD=3.2). The participants rated their quality of life to be 3.9 (SD=1.5). Age at first contact

with psychiatric services was 26.9 years (SD=10.1). The average duration between first

contacts with psychiatric services to the present treatment was 12 years.

 54

In the first paper, we compared three diagnostic groups: the Pure-AvPD group (AvPD

without concurrent SP), the AvPD+SP group, and the Pure-SP group. In the second and fourth

papers, the sample was divided into two groups: the AvPD group (AvPD with and without

SP; n=71) and the SP group (SP without AvPD; n=20). Eighteen patients (90%) in the SP

group had GSP. Sociodemographic characteristics did not differ significantly between the

groups (Table 4) except that only 26% of the patients in the AvPD+SP group and 40% in the

Pure-AvPD group were working half-time or more, compared with 60% in the Pure-SP group

(p<0.01). In paper IV, ECR data from one patient with both AvPD and SP were missing,

reducing the sample size to 90.

Insert table 4 about here

The sample of paper III consisted of 495 patients with a majority of females (78%)

and a mean age of 30 years (SD=7). In this sample, 24% were married or cohabiting, and 39%

were living alone. They had an average of 6 years of education after junior secondary school

(SD=12.5) and had been working 5 of the last 12 months (SD=4.8). According to DSM-IV,

91% had at least one PD diagnosis, and 96% had at least one symptom disorder: 68% mood

disorders, 66% anxiety disorders, and 18% substance-related disorders. Mean GSI (Global

Severity Index of SCL-90-R) was 1.7 (SD=0.7), mean number of symptom disorders was 2.4

(SD=1.6), mean number of PD criteria was 13.6 (SD=6), and the average lowest GAF score

was 49 (SD=7).

5 RESULTS

5.1 Personality functioning in patients with Avoidant Personality Disorder and Social

Phobia (Paper I). We found that patients in the two AvPD groups had more additional Axis I

diagnoses compared with those in the Pure-SP group. Patients with both disorders also had
 55

more problems in work and social adjustment and more symptoms than the Pure-SP group,

but no differences were found among the groups in levels of depression.

As to the extent of Axis II pathology, the two AvPD groups met more PD criteria for

other PDs compared with the Pure-SP group. The Pure-SP group had on average 2.2

(SD=0.09) avoidant criteria; i.e., 80% of them met two or three AvPD criteria, thus

representing a sub-threshold AvPD group. In this sample, the AvPD+SP group met more

AvPD criteria than the Pure-AvPD group.

The groups differed significantly on many measures but not on the CIP sum. The

differences had medium to large effect sizes and could indicate that the AvPD group had more

problems with psychosocial, identity, and relational functioning than patients with SP only.

When taking into account the presence of SP, other symptom disorders, and PDs, we found

that AvPD added significantly to the explained variance in self-esteem (ISE), work and social

adjustment (WSAS), mistrust (CIP), and several facets of the identity and relational domain

(SIPP-118), but not in the facets enjoyment and self-reflexive functioning (SIPP-118).

These results indicate that problems with low psychosocial functioning, low self-

esteem, high mistrust, and low functioning regarding self-respect, intimacy, feeling

recognized, and cooperation are all closely connected to AvPD pathology.

5.2 Avoidant Personality Disorder versus Social Phobia: The significance of

childhood neglect (Paper II)

We compared temperament and childhood experiences in patients with AvPD with

and without concurrent SP (AvPD group) with patients in the SP group (patients with SP

without AVPD). In line with our hypothesis, the AvPD group had significantly higher scores

on physical neglect, as well as on the composite neglect variable, with emotional neglect

showing a trend, all compared with the SP group. However, contrary to our expectations, the
 56

groups did not differ significantly in emotional, physical, or sexual abuse although there was a

trend towards more abuse in the AvPD group, as measured by the composite abuse variable.

In addition, in agreement with our hypothesis, the AvPD-related difference in neglect

remained significant when controlling for physical, sexual, and emotional abuse and

temperamental differences by ANCOVA.

Contrary to our hypothesis, there were no between-group differences in perceived

parental style (PBI) or in the dimensional scales care nor control. The great majority in both

groups reported their parents to be low on care. The results indicate that childhood neglect

could be a risk factor for AvPD and may be contributing to the phenomenological differences

between AvPD and SP.

5.3 Experiences in Close Relationship - Psychometric properties among patients

with personality disorders (Paper III)

The aim of this study was to investigate the psychometric properties of the Norwegian

version of ECR and the two proposed short forms ECR-S and ECR-N12 in a sample of

patients with PDs. An internal consistency and confirmatory factor analysis of ECR, ECR-S,

and ECR-N12 from 495 patients with PDs was conducted, as well as an exploratory factor

analysis of ECR. Despite high values of Cronbach’s alpha, the internal consistency of ECR

was found to be questionable. Confirmatory factor analysis revealed a poor fit to the two

factor model for the ECR and ECR-S. The ECR-N12 revealed a mediocre fit, indicating a

potential for improvement. An exploratory factor analysis was conducted with all 36 items of

the ECR and resulted in six factors with eigenvalues greater than 1, accounting for 62% of the

variance. Factor six was defined by three items only. Conceptually, this factor gave no clinical

meaning and was not considered further. The remaining five factor model (ECR-FF)

accounted for 58% of the variance. A CFA of the ECR-FF revealed good fit, and
 57

conceptually, the factors were “Avoidance of closeness,” “Uncomfortable with openness,”

“Separation frustration,” “Anxiety for abandonment,” and “Frantic desire for closeness.”

The results indicated that interference from scale scores based on ECR should be

derived with considerable care in a sample of patients with PDs. The multidimensionality of

ECR may have the potential for a more nuanced picture of attachment-related anxiety and

avoidance. Further studies are needed to investigate the validity of ECR-FF, especially among

different clinical samples.

5.4 Attachment styles in patients with Avoidant Personality Disorder compared

with Social Phobia (Paper IV)

We compared attachment styles in patients with AvPD with and without concurrent SP

(AvPD group) with patients in the SP group (patients with SP without AVPD). In line with

our first hypothesis, the AvPD group had a higher mean score on the Anxiety scale than the SP

group. However, contrary to the hypothesis, the difference on the Avoidance scale was not

significant.

In accordance with the second hypothesis, the AvPD group had a higher score on

Anxiety for abandonment and Separation frustration. The effect sizes of the differences were

large and medium, respectively. After controlling for gender and age, number of other PD

criteria, number of other symptom disorders, SP, and the other attachment factors, the

attachment factor Anxiety for abandonment explained a significant addition of the variance in

AvPD severity. Results of a Chi-squared test of the four categories of attachment styles and

the two diagnostic groups were not statistically significant; however, when performing four

separate Chi-squared tests, one for each attachment category, Fearful was significantly more

frequent in the AvPD group than in the SP group, as hypothesized, whereas the Dismissing
 58

style was significantly more frequent in the SP group than in the AvPD group. The Secure

attachment style was the least frequent style in both groups.

The results indicate a large variation of attachment problems in both disorders.

Compared to SP, AvPD seems to be more strongly associated with attachment anxiety, in

particular fear of abandonment.

6. DISCUSSION

6.1 Main findings papers I, II, and IV

The relation between AvPD and SP is still disputed, and several open questions remain. Is

AvPD just a more severe variant of SP, and if so, in what way? Is AvPD a more severe mental

disorder than SP in aspects other than social anxiety and functioning, like personality

pathology and functioning, temperament, childhood experiences, and attachment? Is it

possible to distinguish between AvPD and SP by some of these variables? Could AvPD

justify its position as a PD? Are those with both disorders a more severely functioning group

than those with Pure-AvPD? Could AvPD and SP be distinguished by underlying dimensions

other than social anxiety? In the following, we discuss the present findings in light of these

questions.

6.1.1. Personality pathology and functioning

In paper I, we compared clinical characteristics in three diagnostic groups of patients: Pure-

SP, Pure-AvPD, and AvPD+SP. We found that patients with AvPD had more symptom

disorders, symptom distress, and psychosocial dysfunction compared with patients in the

Pure-SP group. Regarding symptom distress and psychosocial dysfunction, however, only

patients in the AvPD+SP group differed from those with Pure-SP in a statistically significant

way. This finding could, of course, be due to the additional burden of co-occurring disorders,
 59

but could also be due to Type II error because both the Pure-AvPD and Pure-SP groups were

small. However, the higher psychosocial distress among patients in the AvPD+SP group

might also be related to the fact that they met more AvPD criteria on average than those with

AvPD only. The multivariate analyses indicated that AvPD contributes to psychosocial

distress over and above the presence of SP. Overall then, these results are in agreement with

earlier research finding AvPD to be a generally more severe disorder than SP regarding

symptoms and psychosocial functioning (Bögels et al., 2010; Reich, 2013).

Additionally, we investigated if AvPD can be distinguished from SP on various

aspects of personality pathology and functioning. The diagnostic interviews revealed more

criteria of other types of PDs in the two AvPD groups, which indicate that AvPD is associated

with a broader range of personality pathology than SP. This result is in accordance with the

findings of Hummelen et al. (2007) and is particularly noteworthy because we excluded

patients with co-occurring PDs in clusters A and B.

Patients in the two AvPD groups also had more problems with self-esteem, mistrust,

and other identity and relational functioning. These differences had medium to large effect

sizes.

Contrary to our hypothesis, however, CIP sum was not significantly different between

the groups. Thus, the total amount of interpersonal problems measured by CIP may be quite

similar but still differ on the subscales mistrust, social avoidance, and coldness.

The results of the multivariate analyses indicate that problems with low psychosocial

functioning, low self-esteem, high mistrust, and low functioning regarding self-respect,

intimacy, a feeling of being recognized by others, and cooperation are all closely connected to

AvPD pathology. We controlled for symptom disorders, other PDs, and the presence of SP,

which is a rather strict level of statistical control because the propensity for a broader load of

symptom and personality pathology probably is an inherent aspect of avoidant pathology.

 60

Few studies have investigated personality pathology and functioning in AvPD and SP.

Hummelen and co-workers (2007) hypothesized that AvPD and SP involve different degrees

of self-pathology, with dysfunctional defense strategies to maintain self-esteem and self-

coherence. The present finding suggests that patients with AvPD have a more vulnerable

sense of self and less self-reflexiveness to assist with affect regulation in relational contexts.

They may depend on pervasive avoidant strategies to preserve self-coherence (Bijttibier,

1999; Fonagy & Target, 1997). Their interpersonal distancing does not seem restricted to

social performance situations but affects their capacity for intimacy as well, in concordance

with the theory of Millon (1981). In contrast, patients with SP exhibit greater self-reflexive

functioning and greater self-respect and stability of self-image, thereby allowing better affect

regulation, more interpersonal contact and intimacy, and less devastating psychosocial

consequences.

The results thus indicate that patients with AvPD may be distinguished from patients

with SP by a more severe and a broader area of personality pathology and by more

maladaptive personality functioning in the core aspects of personality, i.e., the identity and

relational domains. According to the effect sizes of the between-group differences, the two

AvPD groups seem to be more similar to each other than each one is to the Pure-SP group,

despite some exceptions. On the other hand, we cannot conclude from these data that AvPD

and SP are qualitatively distinct disorders because personality functioning tends to have a

dimensional distribution. Then, the question could be where to set the bar (Diamaggio et al.,

2013). The discussion of whether AvPD and SP are different disorders is part of a larger

debate about the relationship between symptom disorders on Axis I and PDs on Axis II

(Kreuher, 2005). However, these results are in line with Hummelen et al. (2007), Ralvski

(2005), and DSM-5 (APA, 2013), supporting the definition and retention of AvPD as a PD in

DSM-5.
 61

Another question, however, is whether the co-occurrence of AvPD and SP represents a

more severe condition than the Pure-AvPD group. Our results are ambiguous: The two AvPD

groups were not different on most personality variables covering identity and relational

functioning; however, patients in the AvPD+SP group had more severe dysfunction regarding

self-esteem, work, and social interactions than those in the Pure-AvPD group. On the other

hand, results from the multivariate analyses suggest that these differences could simply reflect

the fact that the AvPD+SP group met more AvPD criteria than the Pure-AvPD group. Other

studies also give an ambiguous picture at this point: In their clinical study, Ralevski and co-

workers (2005) found that the addition of SP in patients with AvPD did not add to the overall

clinical severity whereas the results of a large epidemiological study from the United States

point in a somewhat different direction (Cox et al., 2009). In an Australian epidemiological

study, Lampe and Sunderland (2015) found that the AvPD+SP group reported more distress

and co-occurring disorders than the Pure-AvPD group.

AvPD without SP is a particularly interesting group and much more frequent than

previously assumed (Reich, 2000). According to recent studies, using DSM-IV, the majority

of patients with AvPD do not meet the criteria for SP (Cox et al., 2009; Hummelen et al.,

2007; Lampe et al., 2015; Ralevski et al., 2005). We do not know if the absence of social

anxiety in these patients reflects a generally lower level of fearfulness, or if their avoidance

strategies effectively prevent them from being exposed to situations that may activate anxiety.

It has been speculated whether AvPD represents an internalization of the social anxiety state

and constitutes a more chronic form of the course of SP (Rettew, 2000). Interestingly, in the

present study, patients with AvPD without concurrent SP reported lower levels of self-

reflexive functioning compared with the AvPD+SP group, pointing toward more problems

with “theory of mind” (Bora, Yucel, & Pantelis, 2009). Probably, these patients represent a

heterogeneous group. AvPD may include underlying dimensions not related to social anxiety,
 62

such as genetic and neurocognitive aspects associated with the schizophrenia spectrum

(Asarnow et al., 2001; Fogelson et al., 2007; Fogelson et al., 2010) and lack of social skills

associated with autism spectrum disorders like Asperger’s disorder (Lunegard et al., 2012).

Thus, this study did not provide any answers about the pure AvPD group but does lead to a

new hypothesis about patients with pure AvPD: Do they have less mentalizing capacity than

those with SP?

6.1.2. Childhood experiences

To explore possible differences in environmental risk factors, we compared childhood

experiences in two diagnostic groups: the AvPD group, comprising patients with AvPD with

and without SP, and the Pure SP group, in papers II and IV called the “SP group.” Both AvPD

and SP were associated with negative childhood experiences, as assessed by CTQ. AvPD was

associated with more self-reported childhood neglect, was significant for physical neglect and

the composite neglect scale, and showed a trend for emotional neglect. No previous studies

have compared AvPD and SP regarding childhood experiences. However, the result is in

agreement with retrospective findings that emotional neglect is predictive of cluster C PDs

(Zhang et al., 2012) and prospective findings that it is predictive of AvPD (Johnson et al.,

2000). The difference between the diagnostic groups was most pronounced for physical

neglect, though. Of note, the AvPD-related difference in neglect remained significant when

we controlled for child abuse as well as temperamental differences. Thus, the results suggest

that the often less dramatic or silent maltreatment experiences of emotional and physical

neglect might be risk factors for adult AvPD over and above the effects of both abuse

experiences and temperamental dispositions.

Neglect is generally defined as the absence of protection, care, and positive attention,

i.e., the parents are physically present but do not attend to the child. Neglect is potentially a
 63

very harmful experience for a child, and the psychological consequences are probably

manifold. From the child’s perspective, physical and emotional needs may be perceived as

irrelevant or too much trouble for the parents. It is easy to understand that a child who is not

given attention, care, and protection within the attachment relationship might develop

assumptions of not being of interest to others and not important or not worthy of being loved.

Correspondingly, neglect may interfere with the child’s development of perceptions of others

as safe sources of comfort, support, and reassurance. Such experiences could be integrated

into the personality as more permanently disturbed representations of self and others, or what

John Bowlby called Internal Working Models (1969) and Jeffrey Young called Early

Maladaptive Schemas (1990), that are characteristic for AvPD. In instances of more severe

neglect, even basic affect regulation and self-coherence may be affected.

In light of the results in paper I that patients with AvPD exhibited more impairment in

self and relational functioning than those with SP, one hypothesis, then, is that different levels

of childhood neglect are among the factors underlying such differences in personality

functioning. In the presence of common constitutional dispositions for AvPD and SP

(Reichborn-Kjennerud et al., 2007), the experience of more severe childhood maltreatment

may be a factor that drives personality development towards avoidant personality pathology

(Joyce et al., 2003).

It is important to recognize, however, that a child’s temperamental make-up may have

a bidirectional effect, i.e., exert a certain influence on the parents’ child-rearing behavior, and

at the same time render the child more vulnerable to specific responses from the caregivers

(Nederlof et al., 2010). Maltreatment probably affects children differently and interacts with

both constitutional and environmental risk and resilience factors. For example, temperamental

factors may render a person more vulnerable to developing AvPD or SP if they are exposed to

neglect or abuse but also are more at risk for being neglected or abused.
 64

In contrast to the results based on the CTQ, no between-group differences were detected

regarding the PBI. A majority of the patients in both groups associated their parents with low

care (i.e., the neglecting or cold control parental style). The fact that the PBI did not

differentiate between the disorders in this sample is in agreement with other studies (Burbach,

Kashani, & Rosenberg, 1989; Rey, Bird, Kopec-Schrader, & Richards, 1993; Rey & Plapp,

1990; Rusell, Kopec-Schrader, Rey, & Beumont, 1992). The dimensions assessed by the PBI

might represent non-specific vulnerability factors for psychopathology across various

psychiatric disorders (Rey et al., 1993). On the other hand, it might also be due to

methodological variations. Their experiences of neglect or abuse may have influenced the

way they perceived their parents, i.e., with less ability to report their parents’ parental

behavior as dysfunctional or deviating from a norm.

6.1.3. Attachment style

Given the indications from theories, previous research, and paper I that AVPD is associated

with intimacy problems, AvPD and SP could be associated with different levels or types of

problems in close relationships, reflecting underlying differences in attachment. Thus, in

paper IV, we compared attachment styles in patients with AvPD and SP. Both diagnostic

groups had high levels of attachment anxiety and avoidance, and the large majority in both

groups had an insecure attachment style. As hypothesized, the AvPD group had higher scores

on the Anxiety dimension than the SP group, indicating more attachment problems among

patients in the AvPD group. This is in line with theoretical, clinical, and research indices

showing that close relationships and intimacy are more troublesome to patients with AvPD

than to those with SP (APA, 1994, 2013; Hummelen et al., 2007; Marques et al., 2012;

Millon, 1981).
 65

In contrast to our expectation, the scores for the two diagnostic groups did not differ

significantly for the Avoidance dimension. This finding suggests that negative expectancies

towards unfamiliar people, typical for SP, also may pertain to close relationships. The

definitions of AvPD and SP include negative expectancies in relation to others, outlined as

fears of humiliation and critical scrutiny in SP and fear of rejection in AvPD (APA, 1994,

2013). Thus, patients with SP and AvPD could have quite similar avoidant strategies for

handling imagined negative responses from others that might become close. Yet, the majority

of patients in the SP group had GSP. Avoiding intimacy could be more characteristic of GSP

than circumscribed SP. On the other hand, it might be that the self-reported assessment of

avoidance measures only certain types of avoidance whereas more subtle and maybe more

central aspects remained unstudied here. Future research should use other methods, such as

the AAI, to elaborate on similarities and differences in attachment between these disorders,

including more unconscious aspects of avoidance.

Both diagnostic groups had high levels of attachment anxiety and avoidance compared

with a Norwegian community sample (Olssøn & Dahl, 2010). Moreover, both the levels and

the differences between the diagnostic groups in the present sample are in line with the

findings of Ehrenthal et al. (2009) and Olssøn and Dahl (2014), which suggest a dimensional

gradient of increasing attachment problems with increasing psychopathology, from the normal

population to patients with symptom disorders, such as SP, and further to patients with both

symptom and personality disorders, such as SP and AvPD.

The five ECR sub-factors gave a more nuanced picture of attachment problems and the

differences between the two groups. In paper III, we found that the two-dimensional factor

structure of the ECR was questionable in a sample of subjects with PDs whereas the five

factor solution used here gave a good model fit. The differences between AvPD and SP were

most evident for the sub-factors Anxiety for abandonment and Separation frustration, for
 66

which the AvPD group had higher scores than the SP group, with medium effect sizes.

Moreover, Anxiety for abandonment contributed significantly to the explained variance in

severity of AvPD, over and above age, gender, number of other PD criteria, number of other

symptom disorders, concurrent SP, and the other attachment sub-factors. Thus, attachment

anxiety regarding abandonment seems to be an important aspect of the AvPD pathology. This

result is in line with the finding that AvPD is associated with pessimistic cognitive–affective

responses to rejection-related situations (Meyer et al., 2005). In addition, anxious attachment

has been associated with tendencies to rate neutral faces as less friendly and more rejecting

(Meyer et al., 2004). Our finding is consistent with indices from the research of Schmidt,

Joiner Jr, Young, and Telch (1995): In a preliminary validation study of the Schema

Questionnaire mapping Early Maladaptive Schemas (Young, 1990), the EMS

“Abandonment” was strongly associated with avoidant personality traits. Fear of

abandonment is not part of the existing diagnostic criteria but sheds light on the restraint in

intimate relationships (APA, 1994). Fear of being abandoned could be an underlying aspect of

the fear of intimate relationships. In clinical practice, we often find patients with AvPD saying

that “if somebody would know who I really am, they would abandon me.” Gunderson and

Lyons-Ruth (2008) have proposed a model of a neurobiologically based interpersonal

hypersensitivity in patients with Borderline PD. This hypersensitivity may also pertain to

AvPD and play a part in the intense fear of abandonment in these patients.

The large majority of participants in both diagnostic groups had an insecure

attachment style, according to the categorical model of Bartholomew (1990). Of note, within

each diagnostic group, the distribution of the different types of insecure attachment styles was

heterogeneous. This finding indicates that attachment problems are highly individual and

differ within diagnoses. Yet, the Fearful attachment style was more frequent in the AvPD

group. This style may reflect a deep conflict between approach and withdrawal urges, with
 67

resemblance to the Disorganized/Unresolved or Cannot classify attachment pattern (Main &

Hesse, 1990; Main & Solomon, 1986). Both the Fearful style and the Disorganized or Cannot

classify pattern have empirically been associated with AvPD (Fossati et al., 2003; Nakash-

Eisikovits et al., 2002; Riggs et al., 2007; Rindal, 2000). These findings point to an internal

emotional conflict in patients with AvPD between longing for attachment and high attachment

anxiety with intimacy avoidance as a defense against potentially overwhelming affects. Even

if this result should be considered with care due to statistical limitations (see below), one may

speculate that some patients with AvPD actually have a Disorganized attachment pattern with

no preferred attachment strategy and that their avoidance behavior in intimate relationships is

a necessary defense to maintain coherence. Overall then, patients with AvPD may represent a

wide range of severity of attachment problems, from Secure to Disorganized.

The surprising finding that the Dismissing attachment style was more frequent in the

SP group contradicts previous research, which has found the Anxious–Ambivalent attachment

pattern and the Secure attachment styles were associated with SP (Bar-Haim et al., 2007;

Bifulco et al., 2006; Brook & Schmidt, 2008; Eng et al., 2001; Warren et al., 1997). In the

original model of Bartholomew (1990), patients with a Dismissing style have a positive view

of self. Thus, the result also contradicts our clinical experience and the finding that patients in

the SP group have considerable problems with self-esteem (measured by the ISE, Table 1).

Haggerty, Hilsenroth, and Vala-Stewart (2009) found that the Dismissing style was associated

with interpersonal problems of being cold and dominant. In paper I, we found that both AvPD

and SP were associated with being cold, but not dominant. One may question the

appropriateness of the model of Bartholomew, at least in this sample. There is also

uncertainty associated with the psychometrics of the model when applied in this sample; see

6.2.3. At present, the extent of dismissiveness in patients with SP and AvPD seems unclear

and should be studied further.

 68

The results indicate that AvPD is associated with more attachment anxiety than SP,

especially regarding fear of being abandoned. Fear of abandonment may play a significant

role in the AvPD pathology.

6.2 Methodological issues, strengths, and limitations of papers I, II, and IV

6.2.1 Design: a cross-sectional, clinical, multi-site study

The main strengths of this thesis are the direct comparison of personality functioning,

childhood experiences, and attachment problems in thoroughly assessed patients with AvPD

and SP, and the use of appropriate instruments. This study is the first to compare the two

diagnoses on these variables.

The cross-sectional design precludes any conclusions about causality. It may,

however, increase our knowledge of associations here and now and stimulate further

hypotheses. Previous clinical studies that compared AvPD and SP have recruited patients

either from an anxiety population (Eng et al., 2001; Marques et al., 2012) or from a

population of personality pathology (Hummelen et al., 2007; Ralevski et al., 2005). In our

multi-site design, we included patients both from anxiety clinics treating SP and from units

specialized in assessing and treating PDs.

The multi-site design is challenging regarding representativeness. Although the

therapists received the same information about the study, they may have had different

attitudes and traditions regarding recruitment of patients to clinical research. Thus, they may

have selected the patients differently, giving a selection bias. Unfortunately, we have no data

about the patients who were not invited to participate or those who rejected participation, so

we could not control statistically for these possible differences.

6.2.2 Sample
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Inclusion of impaired patients with fully developed disorders indicates that the results may be

clinically relevant. However, the patients in this sample had longstanding disorders and were

poorly functioning. The mean interval from their first contact with psychiatric services to

treatment at the time of inclusion was 12 years, and few of them were working full time. The

majority of the patients in the SP group had GSP and thus do not represent the full range of

patients with SP. The exclusion of patients with concurrent cluster A and B PDs further

limited the representativeness of the sample, and the results cannot be generalized to patients

with AvPD and SP in a more general psychiatric population without caution. On the other

hand, despite the high rate of GSP, we detected significant and clinically meaningful

differences in personality functioning, experiences of childhood neglect, and adult attachment

problems between the diagnostic groups.

The patients were included in the study regardless of time in therapy. Unfortunately,

we had no measure of time in therapy or type of therapy. Treatment may have influenced

their answers in different ways. For example, focusing on some of their problems in therapy

may lead to an increased score on self-report of those problems and a reduced value for

problems that were not in focus. If patients with AvPD in this sample had more therapeutic

focus on their childhood experiences, the differences found in CTQ could be an effect of

different treatments for patients with AvPD and SP. However, we have no information in

support of such an interpretation. On the contrary, there is no “treatment of choice” for

AvPD, and the patients with AvPD in this sample were recruited from all the treatment

centers with a variety of treatments available.

Patients in group therapy may compare their problems with the problems of the other

group members, thus ranking their own problems either lower or higher than they otherwise

would have done. We do not know if patients with AvPD in this sample were treated in
 70

groups more than those with SP. If we had obtained such information, we could have

controlled statistically for the differences.

Another variable that we did not measure is the severity of social anxiety – using the

Liebowitz Social Anxiety Scale (Liebowitz, 1987), for example – thus also precluding direct

comparison with other studies. Also, we could not control for the effect of this possible

confounding variable when comparing the SP and AvPD groups. However, we controlled for

the number of Axis I diagnoses, as a representation of the range of symptom distress.

The main limitation of this sample is the small sample size, which carries an increased

risk for Type II errors. Because of the few patients with AvPD without concurrent SP in this

sample, we merged patients with AvPD with and without concurrent SP into one AvPD group

in papers II and IV. This choice may have camouflaged possible differences between the

AvPD patients with and without concurrent SP.

6.2.3 Statistical analyses

The small sample size increased the risk of Type II errors, which is the possibility of not

detecting real differences and getting false-negative results. We performed many statistical

analyses and increased the risk of Type I errors, i.e., by chance finding differences that are not

true and getting false-positive results. We did not apply any standard correction technique,

such as the Bonferroni method, to compensate for the risk of Type I errors by using many

statistical tests because we considered the risk of Type II errors higher than the risk of Type I

errors in this thesis, due to the small sample size. Thus, one has to keep in mind the possibility

of Type I errors when interpreting the results. The small sample size is especially statistically

challenging when performing categorical analyses, such as Chi-squared tests of the 2 × 4 table

of the two diagnostic groups and the four categories of parental styles in paper II, and

attachment styles in paper IV, because some also may have low numbers. None of these tests
 71

reached statistical significance, possibly because of Type II errors. Thus, inferences from the

analyses with pure diagnostic groups in paper I and the categorical analyses of parental styles

in paper II and of attachment categories in paper IV should be made with caution.

A statistical strength is the use of effect sizes when finding statistically significant

differences, as additional information about the strength of the results. Among the strengths is

also the use of strict statistical control: First, we controlled for other Axis I and Axis II

disorders when we analyzed the association between the personality functioning and the two

diagnoses. Next, we controlled for temperamental differences and concurrent abuse when

analyzing the association between neglect and AvPD. Lastly, we controlled for age, gender,

other PD criteria, and symptom disorders in the study of associations among the five

attachment factors and severity of AvPD.

To compute the four attachment styles for paper IV, we used classification coefficients

based on Fisher’s linear discriminant functions, estimated by Brennan, Clark, and Shaver

(1998) in a student sample. Such coefficients may be sample dependent, making the current

categorization somewhat uncertain.

Overall, we performed the analyses on the background of theories, results of previous

studies, and our long clinical experiences with these patients.

6.2.4 Assessments

Except for the diagnostic assessments, all background and clinical variables were based on

self-report instruments. The included instruments have previously been well tested and found

to have a high degree of validity and reliability. In paper I, we used the ISE and the SIPP-118;

in paper II we used the ATQ, PBI, and CTQ; and in paper IV, we used the ECR. In paper IV,

we supplemented our analyses with the five sub-factors of ECR, as outlined in paper III,

which probably is a more robust solution in this sample than the original model of two factors.
 72

On the other hand, generally speaking, self-report could be biased by several factors

like social desirability, self-deceit, and current symptoms, which may have affected these

patients. In addition, patients with AvPD may have a general difficulty in appreciating mental

states (Dimaggio, Attiná, Popolo, & Salvatore, 2012; Semerari et al., 2014). Lack of insight

and unconscious processes may be especially crucial when reporting one’s own attachment

style and childhood trauma. Thus, a clear limitation in this thesis is the use of self-report as

the only measure of childhood experiences and attachment. Other studies have used

longitudinal designs with additional informants like state registers, parents, and teachers

(Children In the Community Study; Johnson et al., 2000; Uppsala Longitudinal Study; Bohlin

& Hagekull, 2009), getting more reliable data.

Retrospective reports of early memories are vulnerable to reconstructive bias resulting

from mood and personality, and to the processes of “forgetting.” Although certain specific

traumatic events may stand out as unusual or extreme, abuse and neglect are often part of an

ongoing pattern and may be stored as scripted or generic memories – recurring themes – more

than details of the specific events. The CTQ attempts to elicit these scripted memories by

asking respondents how often past events happened, rather than the details of traumatic

memories (Bernstein & Fink, 1998). Moreover, underreporting is probably a larger threat to

validity in retrospective reports than false-positive reports (Fergusson, Horwood, &

Woodward, 2000; Widom & Morris, 1997; Widom & Shepard, 1996; Williams, 1994). The

denial scale of the CTQ aimed to detect such false-negative reports. In this sample, eight

patients scored on the denial scale, and only two had a full score. Still, no differences were

detected when data were analyzed with and without these eight patients. In the present

sample, patients received different types and lengths of psychotherapy, which may have

influenced their ability to report on childhood trauma.

 73

The discrepancy between information from CTQ and PBI is a limitation here but may

be due to different methodology. CTQ asks for frequencies of different types of maltreatment

whereas PBI asks how they perceive their parents’ behavior. The patient’s perception of their

parent’s behavior might be influenced or distorted by their actual experiences with the

parents.

An important question is whether it is possible to assess personality functioning

reliably by self-report. The ability to report one’s own personality functioning is, of course,

dependent on many factors like insight, social desirability, self-deceit, current symptoms, and

treatment. Another possibility is to use shared variance based on peer and self-report data like

Rodebaugh et al. (2010) did when they studied interpersonal problems in a student sample, or

shared variance between therapist and self-report, or interviews. However, previous studies

indicate that SIPP-118 has good concurrent and discriminatory validity, test–retest reliability

(Andrea, 2007), and cross-national validity (Arnevik et al., 2009b). The reliability was good

on all five domains and most facets (Arnevik et al., 2009b). It is not yet known to what extent

SIPP-118 covers personality functioning in the AMPD of DSM-5. The interview assessing the

level of personality functioning according to the Level of Personality Functioning Scale in the

AMPD is under development and is not yet compared with SIPP-118. The LPFS interview

was not available when the data in this thesis were collected.

6.3 Psychometrics of ECR in a sample of personality disorders

In paper III, we investigated the psychometric properties of the ECR in a clinical sample of

individuals with mainly PDs. Additionally, two proposed short forms of ECR were

analyzed. The main findings were as follows: 1) Confirmatory factor analyses at item level

revealed poor fit to a two factor solution for the full ECR and the ECR-S, but the ECR-N12

indicated some potential for improvement. 2) Internal consistency of items comprising

 74

Avoidance and Anxiety were good to excellent for all three versions, as indicated by

Cronbach’s alpha. 3) Exploratory factor analysis of ECR revealed five factors, with low to

moderate inter-correlations. Confirmatory factor analysis revealed a good model fit to the

five factor solution based on 24 of the original 36 items. In the following, we will discuss

these findings.

The high internal consistencies among the items of the ECR subscales, as measured by

Cronbach’s alpha, were in accordance with several former studies of ECR. This agreement,

however, was found to conceal two major concerns. First, they were representing

multidimensionality, and second, many pairs of items were highly correlated paraphrases of

each other. Thus, the assumptions for the use of Cronbach’s alpha, i.e., homogeneous scales

with a similar mean co-variation, are not confirmed, and one should be careful about drawing

inferences from these scale scores.

In accordance with Olssøn et al. (2010), we also found a poor model fit of the ECR-S.

However, the ECR-N12 revealed a mediocre model fit, indicating some potential for

improvement. The two short forms are somewhat different in their operationalization of

avoidance and anxiety. In general, short forms are usually developed to assess the essence of

variance related to the clinical constructs in question and are therefore prone to excluding

other potentially important clinical information. Future revisions of the short forms thus

should be guided thoroughly by more clearly stated domain-specific definitions of the

constructs, as well as operationalizations by item compositions free of redundancies due to

paraphrases. We recommend that the ECR-N12 be revised and improved to assess the

constructs of Avoidance and Anxiety.

From the item pool of ECR, a five factor solution based on 24 items indicates potential

for clinical utility that is far better than the two factor solution, in that the ECR-FF gives a

more differentiated picture of attachment strategies. Our five factor model, ECR-FF, was
 75

nearly identical to that reported by Olssøn et al. (2010) from their community sample.

However, there is a possibility that the present five factors are highly sample dependent, and

one should be careful generalizing the findings of this study to samples representing clinical

features other than PDs.

Further exploration of the ECR-FF revealed good internal consistency of the scales,

but not without some concerns: First, the scales were composed by a somewhat limited

number of items given the aim to fully cover such a broad latent construct as indicated by

their labels. Second, two items under ‘Separation frustration’ almost address the same aspect,

with a highly significant correlation of 0.65. Third, two items under ‘Anxiety for

abandonment’ are mere negations of each other, with a highly significant correlation of 0.68.

The diverse findings of Wei et al. (2007), Olssøn et al. (2010), and the current study

suggest two things. First, the internal structure of ECR varies across community samples from

the Hedemark county of Norway, undergraduate student samples from USA, and PD samples

from Oslo in Norway. Second, somewhat surprisingly, the current study did not replicate the

good model fit for ECR-N12 but nevertheless found the same factor structure of ECR based

on exploratory analysis. Therefore, further investigation of the psychometric properties of

ECR is warranted, especially in other community and clinical samples. If more firm

documentation appears that ECR comprises five rather than two latent constructs, it may have

potential for a more nuanced assessment of attachment avoidance and anxiety.

6.4 Clinical implications

The more severe and broader personality pathology and dysfunction in the patients with

AvPD suggest that it is reasonable to continue classifying AvPD as a PD and that focusing

treatment solely on social anxiety will probably be insufficient. Identity and relational

problems should be assessed in clinical work with AvPD. Treatment programs for patients
 76

with AvPD should address their identity problems regarding self-esteem and self-respect and

their profound relational problems regarding mistrust with fear of abandonment, including

problems with enduring relationships, intimacy, and cooperation. Indices from this study

combined with the literature also suggest that emotional dysfunction in patients with AvPD

seems to be an important area for therapy.

Treatment should take into account that many patients with AvPD and SP may have

experiences of childhood neglect. Knowledge about their experiences of neglect and abuse

could be crucial for understanding the basis of their identity and relational problems and for a

good therapeutic attunement, helping them to stay in the therapeutic relationship long enough

to foster self-acceptance.

The variation in attachment styles and severity of attachment problems within each

diagnostic group indicates a need to assess attachment in individual patients. A patient’s

attachment style will influence his/her way of relating to the therapist. Thus, these results are

important to better understand the relational perceptions and expectations of patients with

AvPD and SP and the possibility for a better attunement by the therapist. Our results indicate

that patients with AvPD, despite their silence, emotional guardedness, and behavioral

avoidance in social settings, may be longing for a trusting and accepting relationship. This

possible longing is important to keep in mind when the therapist may feel rejected or confused

by the patient’s avoidance strategies. For example, the therapist may be aware that their

emotional guardedness and drop-outs of sessions could be a way of regulating strong,

intolerable attachment anxiety. In this way, drop-outs may elicit empathy instead of irritation

or other negative counter transferences by the therapist, and the patients may feel understood.

It is my hope that these results may contribute to a better clinical understanding of patients

with AvPD and SP.

 77

Based on the psychometric findings, we will recommend that inferences should be

drawn with care when the full 36-item ECR is used to assess the two constructs of avoidance

and anxiety among patients with PDs.

6.5 Implications for further research

Many questions regarding the relationship between AvPD and SP remain to be addressed

in future studies. Underlying dimensions other than social anxiety have not been studied and

compared in pure groups of AvPD and SP and should be investigated. It is still unclear

whether patients with concurrent AvPD and SP represent a more disabled and suffering group

that the pure AvPD patients. There is a need for replication in larger samples with pure

diagnostic groups. Moreover, studying affect regulation in patients with AvPD and SP may

contribute to further elaboration of the complexity of the relationship between AvPD and SP.

Not much is known about emotional dysfunction in patients with AvPD, which should be an

important area for further research.

The pathways to specific disorders are complex, and more studies with other methods

and designs are needed to increase our knowledge about the relationship among childhood

experiences, temperament, and personality dysfunction in subjects with AvPD and SP. More

epidemiological and longitudinal studies in these areas are welcomed.

Whether AvPD patients without the strong anxiety component inherent in SP differ

from those with co-occurring SP in levels of attachment anxiety is an interesting topic for

future research. Also, the extent of attachment-related avoidance and dismissiveness in

patients with SP and AvPD seems unclear and should be studied further. Future research

should use other methods, such as the AAI, to elaborate on similarities and differences in

attachment between these disorders, including more unconscious aspects of avoidance. If the
 78

finding is replicated that fear of attachment is associated with AvPD, it may have implications

for future revisions of the diagnostic criteria for AvPD.

Because the multidimensionality of ECR seems to capture different aspects of

avoidance and anxiety beyond just two scale scores, further studies are needed to investigate

the validity of ECR-FF, especially among different clinical samples.

There is surprisingly little research into treatment for AvPD given the prevalence,

personal burden, and socioeconomic consequences of the disorder. Above all, it is my hope

that the findings in this thesis will contribute to increased knowledge about AvPD and

stimulate research in treatment for these patients, and that future treatment will bring a better

prognosis for patients with AvPD. There is a huge need for more research and development of

treatment methods for this patient group.

7 GENERAL CONCLUSIONS

The results from the present thesis suggest that AvPD involves more severe and broader

areas of personality dysfunction than SP regarding the core aspects of personality functioning,

i.e., in the identity and relational domains. The more severe impairment in self- and relational

functioning in patients with AvPD supports AvPD as a Personality Disorder in accordance

with DSM-5.

Furthermore, the experience of neglect in childhood could be a risk factor for both

adult AvPD and SP, but most pronounced for AvPD. These findings highlight the potential

toll that not being seen, taken care of, and protected during childhood may have on adult

mental health. Childhood neglect may be part of the relational histories woven into the

identity, self-esteem, and interpersonal patterns of patients with AvPD and may contribute to

different degrees of personality dysfunction in patients with AvPD and SP.

 79

The present findings also indicate that there is a large variation in severity of

attachment problems in patients with AvPD and SP and that both SP and AvPD diagnoses

could be associated with attachment insecurity. However, patients with AvPD may experience

more anxiety in close relationships, especially regarding fear of being abandoned. AvPD may

also be associated with the co-existence of a strong longing for but an intense fear of close

relationships.

The psychometric study of ECR in a sample of patients with PDs suggests that

inferences from scale scores based on ECR in such samples should be derived with

considerable care. Moreover, the variance of the ECR items seems to be accounted for by five

rather than two latent constructs and may have the potential for a more nuanced assessment of

attachment-related avoidance and anxiety. The concept of attachment refers to complex

phenomena that may be difficult to assess. Self-reports are obviously time- and cost-saving.

Hence, despite some limitations, ECR could be a useful tool for assessing adult attachment.
 80

8 REFERENCES

Aarre, T. F. (2003). Phenelzine efficacy in refractory social anxiety disorder: A case series.

Nord J Psychiatry, 57(4), 313-315.

Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: a

psychological study of the strange situation. Hillsdale, N.J.: Lawrence Erlbaum.

Akiskal, H. S., Chen, S. E., Davis, G. C., Puzantian, V. R., Kashgarian, M., & Bolinger, J. M.

(1985). Borderline: an adjective in search of a noun. J.Clin.Psychiatry, 46(2), 41-48.

Alden, L. (1989). Short-term structured treatment for avoidant personality disorder. Journal of

Consulting and Clinical Psychology, 57(6), 756.

Alden, L. E., Laposa, J. M., Taylor, C. T., & Ryder, A. G. (2002). Avoidant personality

disorder: current status and future directions. [Review] [167 refs]. J Pers Disord,

16(1), 1-29.

Alden, L. E., Wiggins, J. S., & Pincus, A. L. (1990). Construction of circumplex scales for the

Inventory of Interpersonal Problems. Journal of Personality Assessment, 55(3-4), 521-

536.

American Psychiatric Association (1980). Diagnostic and statistical manual of mental

disorders DSM-III. Washington, D.C.: American Psychiatric Association.

American Psychiatric Association (1987). Diagnostic and statistical manual of mental

disorders (DSM-III-R). Washington, D.C.: American Psychiatric Association.

American Psychiatric Association (1994). Diagnostic and statistical manual of mental

disorders: DSM-IV. Washington, D.C.: American Psychiatric Association.

American Psychiatric Association (2000). Diagnostic and statistical manual of mental

disorders (DSM-IV-R). Washington, D. C.: American Psychiatric Association

 81

American Psychiatric Association (2013). Diagnostic and statistical manual of mental

disorders: DSM-5. Washington, D.C.: American Psychiatric Association.

Andrea, H. (2007). Measuring the core Componentss of Maladaptive Personality: Severity

Indices of Personality Problems (SIPP-118). http://hdl.handle.net/1765/10066.

http://www.deviersprong.nl/nieuws/27-publicaties.html

Andrews, G., Slade, T., Peters, L., & Beard, J. (1998). Generalized anxiety disorder,

obsessive‐compulsive disorder and social phobia: sources of dissonance between ICD‐

10 and DSM‐IV. Int J Methods Psychiatr Res, 7(2), 110-115.

Arbel, N., & Stravynski, A. (1991). A retrospective study of separation in the development of

adult avoidant personality disorder. Acta Psychiatr.Scand., 83(3), 174-178.

Arnevik, E., Wilberg, T., Monsen, J. T., Andrea, H., & Karterud, S. (2009b). A cross-national

validity study of the Severity Indices of Personality Problems (SIPP-118). Personality

and Mental Health, Vol.3(1), 41-55.

Arnevik, E., Wilberg, T., Urnes, O., Johansen, M., Monsen, J. T., & Karterud, S. (2009a).

Psychotherapy for personality disorders: short-term day hospital psychotherapy versus

outpatient individual therapy - a randomized controlled study. Eur.Psychiatry, 24(2),

71-78. doi: S0924-9338(08)01611-8 [pii];10.1016/j.eurpsy.2008.09.004 [doi]

Asarnow, R. F., Nuechterlein, K. H., Fogelson, D., Subotnik, K. L., Payne, D. A., Russell, A.

T., . . . Kendler, K. S. (2001). Schizophrenia and schizophrenia-spectrum personality

disorders in the first-degree relatives of children with schizophrenia: the UCLA family

study. Archives of General Psychiatry, 58(6), 581-588.

Bamelis, L. L., Evers, S. M., Spinhoven, P., & Arntz, A. (2014). Results of a multicenter

randomized controlled trial of the clinical effectiveness of schema therapy for

personality disorders. American Journal of Psychiatry.

 82

Bar-Haim, Y., Dan, O., Eshel, Y., & Sagi-Schwartz, A. (2007). Predicting children's anxiety

from early attachment relationships. Journal of Anxiety Disorders, 21(8), 1061-1068.

Barber, J. P., Morse, J. Q., Krakauer, I. D., Chittams, J., & Crits-Christoph, K. (1997).

Change in obsessive-compulsive and avoidant personality disorders following time-

limited supportive-expressive therapy. Psychotherapy: Theory, research, practice,

training, 34(2), 133.

Bartak, A., Spreeuwenberg, M. D., Andrea, H., Holleman, L., Rijnierse, P., Rossum, B. V., . .

. Emmelkamp, P. M. (2010). Effectiveness of different modalities of

psychotherapeutic treatment for patients with cluster C personality disorders: results of

a large prospective multicentre study. Psychother.Psychosom., 79(1), 20-30. doi:

000254902 [pii];10.1159/000254902 [doi]

Bartholomew, K. (1990). Avoidance of intimacy: An attachment perspective. Journal of

Social and Personal Relationships, 7(2), 147-178.

Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among young adults: a test of

a four-category model. Journal of Personality and Social Psychology, 61(2), 226.

Beck, A. T., & Freeman, A. (1990). Cognitive therapy of personality disorders. New York:

The Guildford Press.

Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., Erbaugh, J., & Erberich, S. G. (1961). An

inventory for measuring depression. Arch.Gen.Psychiatry, 4, 561-571.

Becker, D. F., Añez, L. M., Paris, M., Bedregal, L., & Grilo, C. M. (2009). Factor structure

and diagnostic efficiency of the Diagnostic and Statistical Manual of Mental

Disorders, criteria for avoidant personality disorder in Hispanic men and women with

substance use disorders. Comprehensive Psychiatry, 50(5), 463-470.

Beesdo, K., Bittner, A., Pine, D. S., Stein, M. B., Hofler, M., Lieb, R., & Wittchen, H. U.

(2007). Incidence of social anxiety disorder and the consistent risk for secondary
 83

depression in the first three decades of life. Arch Gen Psychiatry, 64(8), 903-912. doi:

10.1001/archpsyc.64.8.903

Bender, D. S. (2013). An ecumenical approach to conceptualizing and studying the core of

personality psychopathology: a commentary on Hopwood et al. J Pers Disord, 27(3),

311-319.

Bentler, P.M. (1990). Comparative fit indicies in structural models. Psychological Bulletin,

107, 238-246

Bentler, P. M., & Bonett, D. G. (1980). Significance tests and goodness of fit in the analysis

of covariance structures. Psychological Bulletin, 88, 588-606.

Bernstein, D. P., Ahluvalia, T., Pogge, D., & Handelsman, L. (1997). Validity of the

Childhood Trauma Questionnaire in an adolescent psychiatric population.

J.Am.Acad.Child Adolesc.Psychiatry, 36(3), 340-348.

Bernstein, D. P., & Fink, L. (1998). Childhood Trauma Qusetionnaire; A retrospective Self-

Report. San Antonio: The Psychological Corporation.

Bernstein, D. P., Fink, L., Handelsman, L., Foote, J., Lovejoy, M., Wenzel, K., . . . Ruggiero,

J. (1994). Initial reliability and validity of a new retrospective measure of child abuse

and neglect. Am.J.Psychiatry, 151(8), 1132-1136.

Bifulco, A., Kwon, J., Jacobs, C., Moran, P. M., Bunn, A., & Beer, N. (2006). Adult

attachment style as mediator between childhood neglect/abuse and adult depression

and anxiety. Social Psychiatry and Psychiatric Epidemiology, 41(10), 796-805.

Bifulco, A., Moran, P., Ball, C., & Bernazzani, O. (2002). Adult attachment style. I: Its

relationship to clinical depression. Social Psychiatry and Psychiatric Epidemiology,

37(2), 50-59.

Bijttebier, P., & Vertommen, H. (1999). Coping strategies in relation to personality disorders.

Personality and Individual Differences, 26(5), 847-856.

 84

Blanco, C., Heimberg, R. G., Schneier, F. R., Fresco, D. M., Chen, H., Turk, C. L., . . . Juster,

H. R. (2010). A placebo-controlled trial of phenelzine, cognitive behavioral group

therapy, and their combination for social anxiety disorder. Archives of General

Psychiatry, 67(3), 286-295.

Blanco, C., Schneier, F. R., Schmidt, A., Blanco-Jerez, C. R., Marshall, R. D., Sanchez-

Lacay, A., & Liebowitz, M. R. (2003). Pharmacological treatment of social anxiety

disorder: A meta-analysis. Depression and Anxiety, 18(1), 29-40.

Bleuler, E. (1911). Dementia praecox: Or the group of schizophrenia (J. Zinkin, Trans.). New

York: International Universities Press.

Bogels, S., Stevens, J., & Majdandzic, M. (2011). Parenting and social anxiety: fathers' versus

mothers' influence on their children's anxiety in ambiguous social situations. J Child

Psychol.Psychiatry, 52(5), 599-606. doi: 10.1111/j.1469-7610.2010.02345.x [doi]

Bogels, S. M., Alden, L., Beidel, D. C., Clark, L. A., Pine, D. S., Stein, M. B., & Voncken, M.

(2010). Social anxiety disorder: questions and answers for the DSM-V.

Depress.Anxiety., 27(2), 168-189.

Bohlin, G., & Hagekull, B. (2009). Socio-emotional development: from infancy to young

adulthood. Scand.J.Psychol., 50(6), 592-601. doi: SJOP787 [pii];10.1111/j.1467-

9450.2009.00787.x [doi]

Bora, E., Yucel, M., & Pantelis, C. (2009). Cognitive functioning in schizophrenia,

schizoaffective disorder and affective psychoses: meta-analytic study. Br.J Psychiatry,

195(6), 475-482. doi: 195/6/475 [pii];10.1192/bjp.bp.108.055731 [doi]

Borge, F.-M., Hoffart, A., Sexton, H., Clark, D. M., Markowitz, J. C., & McManus, F. (2008).

Residential cognitive therapy versus residential interpersonal therapy for social

phobia: A randomized clinical trial. Journal of Anxiety Disorders, 22(6), 991-1010.

Bowlby, J. (1969). Attachment. Vol. 1, Attachment and Loss. London: The Hogarth Press.
 85

Bowlby, J. (1973). Attachment. Vo. 2, Anxiety and Anger. London: The Hogarth Press.

Bowlby, J. (1980). Attachment. Vol. 3, Loss: Sadness and Depression. London: The Hogarth

Press.

Bowlby, J. (1988). A secure base. Clinical applications of attachment theory. London:

Tavistock/Routledge.

Bowles, D. P., Armitage, C. J., Drabble, J., & Meyer, B. (2013). Self‐esteem and other‐esteem

in college students with borderline and avoidant personality disorder features: An

experimental vignette study. Personality and Mental Health, 7(4), 307-319.

Brennan, K. A., Clark, C. L., & Shaver, P. R. (1998). Self-report measurement of adult

attachment: An integrative overview Attachment theory and close relationships (pp.

46-76). New York, NY: Guilford Press; US.

Brook, C. A., & Schmidt, L. A. (2008). Social anxiety disorder: a review of environmental

risk factors. Neuropsychiatr.Dis.Treat., 4(1), 123-143.

Buchsbaum, M. S., Yang, S., Hazlett, E., Siegel, B. V., Germans, M., Haznedar, M., . . .

Siever, L. J. (1997). Ventricular volume and asymmetry in schizotypal personality

disorder and schizophrenia assessed with magnetic resonance imaging. Schizophrenia

Research, 27(1), 45-53.

Burbach, D. J., Kashani, J. H., & Rosenberg, T. K. (1989). Parental bonding and depressive

disorders in adolescents. Journal of Child Psychology and Psychiatry, 30(3), 417-429.

Burnham, D. L., Gladstone, A. O., & Gibson, R. W. (1969). Schizophrenia and the need-fear

dilemma. New York: Universities Press.

Carr, C. P., Martins, C. M. S., Stingel, A. M., Lemgruber, V. B., & Juruena, M. F. (2013).

The role of early life stress in adult psychiatric disorders: a systematic review

according to childhood trauma subtypes. The Journal of Nervous and Mental Disease,

201(12), 1007-1020.
 86

Carter, S. A., & Wu, K. D. (2010). Relations among symptoms of social phobia subtypes,

avoidant personality disorder, panic, and depression. Behav.Ther., 41(1), 2-13.

Cattell, R. B. (1957). Personality and motivation structure and measurement. Yonkers,

London: Hoghart press.

Chiesa, M., & Fonagy, P. (2003). Psychosocial treatment for severe personality disorder. 36-

month follow-up. Br.J.Psychiatry, 183, 356-362.

Clark, D. M., Ehlers, A., McManus, F., Hackmann, A., Fennell, M., Campbell, H., . . . Louis,

B. (2003). Cognitive therapy versus fluoxetine in generalized social phobia: a

randomized placebo-controlled trial. J Consult Clin Psychol, 71(6), 1058-1067. doi:

10.1037/0022-006x.71.6.1058

Cohen, J. (1988). Statsistical power analyses for behavioral sciences (second ed.). Hillsdale,

New Jersey: Lawrence Erlbaum associates.

Cohen, P., Crawford, T. N., Johnson, J. G., & Kasen, S. (2005). The children in the

community study of developmental course of personality disorder. J Pers Disord,

19(5), 466-486.

Collins, N. L. (1996). Working models of attachment: Implications for explanation, emotion,

and behavior. Journal of Personality and Social Psychology, 71(4), 810.

Collins, N. L., & Read, S. J. (1990). Adult attachment, working models, and relationship

quality in dating couples. Journal of Personality and Social Psychology, 58(4), 644.

Cox, B. J., Fleet, C., & Stein, M. B. (2004). Self-criticism and social phobia in the US

national comorbidity survey. J Affect Disord, 82(2), 227-234. doi:

10.1016/j.jad.2003.12.012

Cox, B. J., MacPherson, P. S., & Enns, M. W. (2005). Psychiatric correlates of childhood

shyness in a nationally representative sample. Behav.Res.Ther., 43(8), 1019-1027. doi:

S0005-7967(04)00179-2 [pii];10.1016/j.brat.2004.07.006 [doi]

 87

Cox, B. J., Pagura, J., Stein, M. B., & Sareen, J. (2009). The relationship between generalized

social phobia and avoidant personality disorder in a national mental health survey.

Depress Anxiety, 26(4), 354-362. doi: 10.1002/da.20475

Cramer, V., Torgersen, S., & Kringlen, E. (2007). Socio-demographic conditions, subjective

somatic health, Axis I disorders and personality disorders in the common population:

the relationship to quality of life. J.Pers.Disord., 21(5), 552-567.

Crawford, T. N., Shaver, P. R., Cohen, P., Pilkonis, P. A., Gillath, O., & Kasen, S. (2006).

Self-reported attachment, interpersonal aggression, and personality disorder in a

prospective community sample of adolescents and adults. J Pers Disord, 20(4), 331-

351.

Cronbach, L. J. (1951). Coefficient alpha and the internal structure of tests. psychometrika,

16(3), 297-334.

Crowell, J. A., Fraley, R. C., & Shaver, P. R. (2008). Measurement of individual differences

in adolescent and adult attachment Handbook of attachment: Theory, research, and

clinical applications (2nd ed., pp. 599-634). New York, NY: Guilford Press; US.

Cuming, S., & Rapee, R. M. (2010). Social anxiety and self-protective communication style

in close relationships. Behaviour Research and Therapy, 48(2), 87-96. doi:

http://dx.doi.org/10.1016/j.brat.2009.09.010

Davidson, J. R., Foa, E. B., Huppert, J. D., Keefe, F. J., Franklin, M. E., Compton, J. S., . . .

Gadde, K. M. (2004). Fluoxetine, comprehensive cognitive behavioral therapy, and

placebo in generalized social phobia. Arch Gen Psychiatry, 61(10), 1005-1013. doi:

10.1001/archpsyc.61.10.1005

Davila, J., & Beck, J. (2002). Is social anxiety associated with impairment in close

relationships? A preliminary investigation. Behavior Therapy, 33(3), 427-446. doi:

http://dx.doi.org/10.1016/S0005-7894%2802%2980037-5
 88

Derogatis, L. R. (1994). SCL-90-R: Symptom Checklist-90-R: administration, scoring and

procedures manual. Minneapollis, MN: National Computer systems.

Dimaggio, G., Attinà, G., Popolo, R., & Salvatore, G. (2012). Personality disorders with over-

regulation of emotions and poor self-reflectivity—The case of a man with avoidant

and not-otherwise specified personality disorder and social phobia treated with

Metacognitive Interpersonal Therapy. Personality and Mental Health, 6(2), 156-162.

doi: 10.1002/pmh.1193

Dimaggio, G., Carcione, A., Nicolo, G., Lysaker, P. H., d'Angerio, S., Conti, M. L., . . .

Semerari, A. (2013). Differences between axes depend on where you set the bar:

associations among symptoms, interpersonal relationship and alexithymia with

number of personality disorder criteria. J Pers Disord, 27(3), 371-382. doi:

10.1521/pedi_2012_26_043

Dimaggio, G., Semerari, A., Carcione, A., Nicolō, G., & Procacci, M. (2007). Psychotherapy

of personality disorders: Metacognition, states of mind and interpersonal cycles:

Routledge.

Ehrenthal, J. C., Dinger, U., Lamla, A., Funken, B., & Schauenburg, H. (2009). Evaluation

der deutschsprachigen Version des Bindungsfragebogens „Experiences in Close

Relationships-Revised “(ECR-RD). Psychother Psychosom Med Psychol, 59, 315-323.

Eikenaes, I., Gude, T., & Hoffart, A. (2006). Integrated wilderness therapy for avoidant

personality disorder. Nord J Psychiatry, 60(4), 275-281. doi:

10.1080/08039480600790093

Emmelkamp, P. M., Benner, A., Kuipers, A., Feiertag, G. A., Koster, H. C., & van

Apeldoorn, F. J. (2006). Comparison of brief dynamic and cognitive-behavioural

therapies in avoidant personality disorder. The British Journal of Psychiatry, 189(1),

60-64.
 89

Eng, W., Heimberg, R. G., Hart, T. A., Schneier, F. R., & Liebowitz, M. R. (2001).

Attachment in individuals with social anxiety disorder: the relationship among adult

attachment styles, social anxiety, and depression. Emotion, 1(4), 365.

Fairbairn, W. R. D. (1940). Psychoanalytic studies of the personality. London: Travistock.

Fehm, L., Pelissolo, A., Furmark, T., & Wittchen, H.-U. (2005). Size and burden of social

phobia in Europe. European Neuropsychopharmacology, 15(4), 453-462.

Feinstein, A. R. (1970). The pre-therapeutic classification of co-morbidity in chronic disease.

Journal of chronic diseases, 23(7), 455-468.

Fenichel, O. (1945). The Psychoanalytic Theory of Neurosis. New York: WW Norton.

Fergusson, D. M., Horwood, L., & Woodward, L. (2000). The stability of child abuse reports:

A longitudinal study of the reporting behaviour of young adults. Psychological

Medicine, 30(3), 529-544.

First, M. B., Gibbon, M., Spitzer, R. L., Williams, J. B. W. & Benjamin, L. S. . (1997). The

Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II).

Washington, DC: American Psychiatric Press.

Fogelson, D. L., Asarnow, R. A., Sugar, C. A., Subotnik, K. L., Jacobson, K. C., Neale, M.

C., . . . Nuechterlein, K. H. (2010). Avoidant personality disorder symptoms in first-

degree relatives of schizophrenia patients predict performance on neurocognitive

measures: the UCLA family study. Schizophr.Res., 120(1-3), 113-120.

Fogelson, D. L., Nuechterlein, K. H., Asarnow, R. A., Payne, D. L., Subotnik, K. L.,

Jacobson, K. C., . . . Kendler, K. S. (2007). Avoidant personality disorder is a

separable schizophrenia-spectrum personality disorder even when controlling for the

presence of paranoid and schizotypal personality disorders The UCLA family study.

Schizophr.Res., 91(1-3), 192-199.

 90

Fonagy, P., & Target, M. (1997). Attachment and reflective function: their role in self-

organization. Dev.Psychopathol., 9(4), 679-700.

Fossati, A., Feeney, J. A., Donati, D., Donini, M., Novella, L., Bagnato, M., . . . Maffei, C.

(2003). Personality disorders and adult attachment dimensions in a mixed psychiatric

sample: A multivariate study. The Journal of Nervous and Mental Disease, 191(1),

30-37.

Fraley, R. C., Waller, N. G., & Brennan, K. A. (2000). An item response theory analysis of

self-report measures of adult attachment. Journal of Personality and Social

Psychology, 78(2), 350.

George, C., Kaplan, N., & Main, M. (1985). Adult attachment interview Berkley: Unpublished

manuscript. Department of Psychology, University of California.

Gjerde, L., Czajkowski, N., Røysamb, E., Ystrom, E., Tambs, K., Aggen, S., . . . Knudsen, G.

(2015). A longitudinal, population-based twin study of avoidant and obsessive-

compulsive personality disorder traits from early to middle adulthood. Psychological

Medicine, 1-10.

Grant, B. F., Hasin, D. S., Blanco, C., Stinson, F. S., Chou, S. P., Goldstein, R. B., . . . Huang,

B. (2005). The epidemiology of social anxiety disorder in the United States: results

from the National Epidemiologic Survey on Alcohol and Related Conditions. Journal

of Clinical Psychiatry.66(11):1351-61,.

Griffin, D. W.., & Bartholomew, K. (1994). The metaphysics of measurement: the case of

adult attachment. In K. Bartholomew & D. Perlman (Eds.), Advances in personal

relationships: Vol. 5. Attchment process in adulthood (pp.17-52). London: Jessica

Kingsley.
 91

Grilo, C. M. (2004b). Factorial structure and diagnostic efficiency of DSM-IV criteria for

avoidant personality disorder in patients with binge eating disorder. Behaviour

Research and Therapy, 42(10), 1149-1162.

Grilo, C. M., Sanislow, C. A., Gunderson, J. G., Pagano, M. E., Yen, S., Zanarini, M. C., . . .

McGlashan, T. H. (2004a). Two-year stability and change of schizotypal, borderline,

avoidant, and obsessive-compulsive personality disorders. Journal of Consulting &

Clinical Psychology.72(5):767-75,.

Gude, T., & Vaglum, P. (2001). One-year follow-up of patients with cluster C personality

disorders: a prospective study comparing patients with "pure" and comorbid

conditions within cluster C, and "pure" C with "pure" cluster A or B conditions.

Journal of Personality Disorders., 15(3), 216-228.

Gunderson, J. G., & Lyons-Ruth, K. (2008). BPD's interpersonal hypersensitivity phenotype:

a gene-environment-developmental model. J Pers Disord, 22(1), 22.

Gunderson, J. G., Stout, R. L., McGlashan, T. H., Shea, M. T., Morey, L. C., Grilo, C. M., . . .

Skodol, A. E. (2011). Ten-year course of borderline personality disorder:

psychopathology and function from the Collaborative Longitudinal Personality

Disorders study. Arch Gen Psychiatry, 68(8), 827-837. doi:

10.1001/archgenpsychiatry.2011.37

Haggerty, G., Hilsenroth, M. J., & Vala-Stewart, R. (2009). Attachment and interpersonal

distress: examining the relationship between attachment styles and interpersonal

problems in a clinical population. Clin Psychol Psychother, 16(1), 1-9. doi:

10.1002/cpp.596

Hambleton, R. K., & Hambleton, R. (2005). Issues, designs, and technical guidelines for

adapting tests into multiple languages and cultures. Adapting educational and

psychological tests for cross-cultural assessment, 1, 3-38.

 92

Hardt, J., & Rutter, M. (2004). Validity of adult retrospective reports of adverse childhood

experiences: review of the evidence. J.Child Psychol.Psychiatry, 45(2), 260-273.

Haslam, N. (2003). The dimensional view of personality disorders: a review of the taxometric

evidence. Clinical Psychology Review, 23(1), 75-93.

Hazan, C., & Shaver, P. (1987). Romantic love conceptualized as an attachment process.

Journal of Personality and Social Psychology, 52(3), 511.

Hazan, C., & Shaver, P. R. (1994). Attachment as an Organizational Framework for Research

on Close Relationships. Psychological Inquiry, 5(1), 1-22. doi:

10.1207/s15327965pli0501_1

Hedges, L. V. (1981). Distribution theory for Glass's estimator of effect size and related

estimators. Journal of Educational and Behavioral Statistics, 6(2), 107-128.

Hernandez, A., Arntz, A., Gaviria, A. M., Labad, A., & Gutierrez-Zotes, J. A. (2012).

Relationships between childhood maltreatment, parenting style, and borderline

personality disorder criteria. J Pers.Disord., 26(5), 727-736. doi:

10.1521/pedi.2012.26.5.727 [doi]

Hesse, E. (2008). The Adult Attachment Interview: Historical and current perspective. In C. J

& S. PR (Eds.), Handbook of attachment; theory, research and clinical applications

(2nd ed., pp. 465-473). New York: Guildford.

Hirshfeld‐Becker, D. R. (2010). Familial and temperamental risk factors for social anxiety

disorder. New directions for child and adolescent development, 2010(127), 51-65.

Hofmann, S. G., & Smits, J. A. (2008). Cognitive-behavioral therapy for adult anxiety

disorders: a meta-analysis of randomized placebo-controlled trials. J Clin Psychiatry,

69(4), 621-632.

Hopwood, C. J., Malone, J. C., Ansell, E. B., Sanislow, C. A., Grilo, C. M., McGlashan, T.

H., . . . Morey, L. C. (2011). Personality assessment in DSM-5: empirical support for

 93

rating severity, style, and traits. J Pers Disord, 25(3), 305-320. doi:

10.1521/pedi.2011.25.3.305

Hopwood, C. J., Morey, L. C., Donnellan, M. B., Samuel, D. B., Grilo, C. M., McGlashan, T.

H., . . . Skodol, A. E. (2013). Ten-year rank-order stability of personality traits and

disorders in a clinical sample. J Pers, 81(3), 335-344. doi: 10.1111/j.1467-

6494.2012.00801.x

Hopwood, C. J., Morey, L. C., Gunderson, J. G., Skodol, A. E., Shea, M. T., Grilo, C. M., &

McGlashan, T. H. (2006). Hierarchical relationships between borderline, schizotypal,

avoidant and obsessive-compulsive personality disorders. Acta Psychiatrica

Scandinavica, 113(5), 430-439.

Horney, K. (1945). Our inner conflicts a cosntructive theory of neurosis. New York: WW

Norton.

Horowitz, L. M., Alden, L., Wiggins, J., & Pincus, A. (2000). Manual for the inventory of

interpersonal problems. United States of America: Psychological Corporation.

Hu, L. t., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure

analysis: Conventional criteria versus new alternatives. Structural equation modeling:

a multidisciplinary journal, 6(1), 1-55.

Hudson, W. W. (1982). The clinical measurment package: A field manual. Chicago: The

Dorsey Press.

Hummelen, B., Wilberg, T., Karterud, S., & G, P. (2007). The Relationship between Avoidant

Personality Disorder and Social Phobia. Comprehensive Psychiatry, 48, 348-356.

Hummelen, B., Wilberg, T., Karterud, S., & Pedersen, G. (2006). An Investigation of the

Validity of the DSM-IV Avoidant Personality Disorder Construct as a Prototype

Category and the Psychometric Properties of the Diagnostic Criteria. Comprehensive

Psychiatry, 47, 376-383.

 94

Iancu, I., Bodner, E., & Ben-Zion, I. Z. (2015). Self esteem, dependency, self-efficacy and

self-criticism in social anxiety disorder. Comprehensive Psychiatry, 58, 165-171.

Isomura, K., Boman, M., Ruck, C., Serlachius, E., Larsson, H., Lichtenstein, P., & Mataix-

Cols, D. (2015). Population-based, multi-generational family clustering study of social

anxiety disorder and avoidant personality disorder. Psychol Med, 45(8), 1581-1589.

doi: 10.1017/s0033291714002116

Jackson, H. J., & Burgess, P. M. (2004). Personality disorders in the community: results from

the Australian National Survey of Mental Health and Well-being Part III.

Relationships between specific type of personality disorder, Axis 1 mental disorders

and physical conditions with disability and health consultations. Soc Psychiatry

Psychiatr Epidemiol, 39(10), 765-776.

Johansen, M. S., Normann‐Eide, E., Normann‐Eide, T., & Wilberg, T. (2013). Emotional

dysfunction in avoidant compared to borderline personality disorder: A study of affect

consciousness. Scandinavian journal of psychology, 54(6), 515-521.

Johnson, J. G., Cohen, P., Brown, J., Smailes, E. M., & Bernstein, D. P. (1999). Childhood

Maltreatment Increases Risk for Personality Disorders During Early Adulthood.

Arch.Gen.Psychiatry, 56, 600-606.

Johnson, J. G., Smailes, E. M., Cohen, P., Brown, J., & Bernstein, D. P. (2000). Associations

between four types of childhood neglect and personality disorder symptoms during

adolescence and early adulthood: findings of a community-based longitudinal study. J

Pers.Disord., 14(2), 171-187.

Joyce, P. R., McKenzie, J. M., Luty, S. E., Mulder, R. T., Carter, J. D., Sullivan, P. F., &

Cloninger, C. R. (2003). Temperament, childhood environment and psychopathology

as risk factors for avoidant and borderline personality disorders. Australian & New

Zealand Journal of Psychiatry., 37(6), 756-764.

 95

Kachin, K. E., Newman, M. G., & Pincus, A. L. (2001). An interpersonal problem approach

to the division of social phobia subtypes. Behavior Therapy, 32(3), 479-501.

Karterud, S., Pedersen, G., Bjordal, E., Brabrand, J., Friis, S., Haaseth, O., . . . Urnes, O.

(2003). Day treatment of patients with personality disorders: Experiences from a

Norwegian treatment research network. J Pers Disord, 17(3), 243-262.

Kendler, K. S., Gruenberg, A. M., & Strauss, J. S. (1981). An independent analysis of the

Copenhagen sample of the Danish adoption study of schizophrenia: II. The

relationship between schizotypal personality disorder and schizophrenia. Archives of

General Psychiatry, 38(9), 982-984.

Kendler, K. S., McGuire, M., Gruenberg, A. M., O'Hare, A., Spellman, M., & Walsh, D.

(1993). The Roscommon family study: I. Methods, diagnosis of probands, and risk of

schizophrenia in relatives. Archives of General Psychiatry, 50(7), 527-540.

Kernberg, O. F. (1996). A Psychoanalytic Theory of Personality Disorders. In J. F. Clarkin &

M. F. e.-a. Lenzenweger (Eds.), Major Theories of Personality Disorder. New York:

Guilford Press. (Reprinted from: Not in File).

Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005).

Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the

National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6),

593-602.

Kessler, R. C., Chiu, W. T., Demler, O., Merikangas, K. R., & Walters, E. E. (2005).

Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National

Comorbidity Survey Replication. Arch.Gen.Psychiatry, 62(6), 617-627. doi: 62/6/617

[pii];10.1001/archpsyc.62.6.617 [doi]
 96

Knappe, S., Beesdo-Baum, K., Fehm, L., Lieb, R., & Wittchen, H.-U. (2012). Characterizing

the association between parenting and adolescent social phobia. Journal of Anxiety

Disorders, 26(5), 608-616.

Knappe, S., Beesdo, K., Fehm, L., Höfler, M., Lieb, R., & Wittchen, H.-U. (2009). Do

parental psychopathology and unfavorable family environment predict the persistence

of social phobia? Journal of Anxiety Disorders, 23(7), 986-994.

Kretschmer, E. (1925). Physique and character. London: Kegan, Paul.

Krueger, R. F. (2005). Continuity of axes I and II: toward a unified model of personality,

personality disorders, and clinical disorders. [Review] [106 refs]. Journal of

Personality Disorders.(3), 233-261.

Kuo, J. R., Goldin, P. R., Werner, K., Heimberg, R. G., & Gross, J. J. (2011). Childhood

trauma and current psychological functioning in adults with social anxiety disorder. J

Anxiety.Disord., 25(4), 467-473. doi: S0887-6185(10)00229-X

[pii];10.1016/j.janxdis.2010.11.011 [doi]

Lampe, L., & Sunderland, M. (2015). Social Phobia and Avoidant Personality Disorder:

Similar but Different? J Pers Disord, 29(1), 115-130.

Leichsenring, F., Beutel, M., & Leibing, E. (2007). Psychodynamic psychotherapy for social

phobia: a treatment manual based on supportive-expressive therapy. Bulletin of the

Menninger Clinic, 71(1), 56-84.

Leichsenring, F., Salzer, S., Beutel, M. E., Herpertz, S., Hiller, W., Hoyer, J., . . . Leibing, E.

(2013). Psychodynamic therapy and cognitive-behavioral therapy in social anxiety

disorder: a multicenter randomized controlled trial. Am J Psychiatry, 170(7), 759-767.

doi: 10.1176/appi.ajp.2013.12081125
 97

Leichsenring, F., Salzer, S., Beutel, M. E., Herpertz, S., Hiller, W., Hoyer, J., . . . Leibing, E.

(2014). Long-term outcome of psychodynamic therapy and cognitive-behavioral

therapy in social anxiety disorder. Am J Psychiatry, 171(10), 1074-1082.

Lenzenweger, M. F. (2006). The longitudinal study of personality disorders: history, design

considerations, and initial findings. J Pers Disord, 20(6), 645-670. doi:

10.1521/pedi.2006.20.6.645

Liebowitz, M. R. (1987). Social phobia. Modern Problems of Pharmacopsychiatry, 22, 141-

173.

Livesley, W. J. (1998). Suggestions for a framework for an empirically based classification of

personality disorder. Canadian Journal of Psychiatry-Revue Canadienne de

Psychiatrie, 43(2), 137-147.

Lopez, F. G., & Gormley, B. (2002). Stability and change in adult attachment style over the

first-year college transition: Relations to self-confidence, coping, and distress patterns.

Journal of Counseling Psychology, 49(3), 355.

Lopez, F. G., Mitchell, P., & Gormley, B. (2002). Adult attachment orientations and college

student distress: Test of a mediational model. Journal of Counseling Psychology,

49(4), 460.

Lorenzini, N., & Fonagy, P. (2013). Attachment and personality disorders: a short review.

Focus.

Lugnegard, T., Hallerback, M. U., & Gillberg, C. (2012). Personality disorders and autism

spectrum disorders: what are the connections? Compr.Psychiatry, 53(4), 333-340. doi:

S0010-440X(11)00132-5 [pii];10.1016/j.comppsych.2011.05.014 [doi]

Lynum, L. I., Wilberg, T., & Karterud, S. (2008). Self-esteem in patients with borderline and

avoidant personality disorders. Scand.J.Psychol., 49(5), 469-477. doi: SJOP655

[pii];10.1111/j.1467-9450.2008.00655.x [doi]
 98

Main, M., & Hesse, E. (1990). Parents’ unresolved traumatic experiences are related to infant

disorganized attachment status: Is frightened and/or frightening parental behavior the

linking mechanism? In M. T. Greenberg, D. Cicchetti & E. M. Cummings (Eds.),

Attachment in the preschool years: Theory, research, and intervention. The John D.

and Catherine T. MacArthur Foundation series on mental health and development

(pp. 161–82). Chicago, IL: University of Chicago Press.

Main, M., & Solomon, J. (1986). Discovery of an insecure-disorganized/disoriented

attachment pattern. In T. B. Brazelton & M. W. Yogman (Eds.), Affective

development in infancy (pp. 95–124). Westport, CT: Ablex.

Marques, L., Porter, E., Keshaviah, A., Pollack, M. H., Van, A. M., Stein, M. B., & Simon, N.

M. (2012). Avoidant personality disorder in individuals with generalized social

anxiety disorder: what does it add? J.Anxiety.Disord., 26(6), 665-672. doi: S0887-

6185(12)00069-2 [pii];10.1016/j.janxdis.2012.05.004 [doi]

Mataix-Cols, D., Cowley, A. J., Hankins, M., Schneider, A., Bachofen, M., Kenwright, M., . .

. Marks, I. M. (2005). Reliability and validity of the work and social adjustment scale

in phobic disorders. Compr.Psychiatry, 46(3), 223-228.

McCullough, L., Kuhn, N., Andrews, S., Kaplan, A., Wolf, J., & Hurley, C. L. (2003).

Treating affect phobia: A manual for short-term dynamic psychotherapy. New York:

The Guildford Press.

McGlashan, T. H., Grilo, C. M., Skodol, A. E., Gunderson, J. G., Shea, M. T., Morey, L. C., .

. . Stout, R. L. (2000). The Collaborative Longitudinal Personality Disorders Study:

baseline Axis I/II and II/II diagnostic co-occurrence. Acta Psychiatrica

Scandinavica.102(4):256-64,.
 99

Meyer, B., Ajchenbrenner, M., & Bowles, D. P. (2005). Sensory sensitivity, attachment

experiences, and rejection responses among adults with borderline and avoidant

features. J.Pers.Disord., 19(6), 641-658. doi: 10.1521/pedi.2005.19.6.641 [doi]

Meyer, B., & Carver, C. S. (2000). Negative childhood accounts, sensitivity, and pessimism:

A study of avoidant personality disorder features in college students. J Pers Disord,

14(3), 233-248.

Meyer, B., Pilkonis, P. A., & Beevers, C. G. (2004). What's in a (neutral) face? Personality

disorders, attachment styles, and the appraisal of ambiguous social cues. J Pers

Disord, 18(4), 320-336.

Mikulincer, M., Shaver, P. R., & Pereg, D. (2003). Attachment theory and affect regulation:

The dynamics, development, and cognitive consequences of attachment-related

strategies. Motivation and Emotion, 27(2), 77-102.

Millon, T. (1969). Modern Psychopathology, a biosocial approach to maladaptive learning

and functioning. Philadelphia: W. B. Saunders.

Millon, T. (1981). Disorders of personality: DSM-III: axis II. New York: Wiley.

Millon, T. (1991). Avoidant Personality Disorder - A Brief Review of Issues and Data. J Pers

Disord, 5(4), 353-362.

Millon, T., & Davis, R. (1997). Millon Clinical Multiaxial Inventory-III Manual .

Minneapolis, MN: National Computer Systems: Inc.

Morey, L. C., Bender, D. S., & Skodol, A. E. (2013). Validating the proposed diagnostic and

statistical manual of mental disorders, 5th edition, severity indicator for personality

disorder. J Nerv Ment Dis, 201(9), 729-735. doi: 10.1097/NMD.0b013e3182a20ea8

Morey, L. C., & Hopwood, C. J. (2013). Stability and change in personality disorders. Annu

Rev Clin Psychol, 9, 499-528. doi: 10.1146/annurev-clinpsy-050212-185637

 100

Morey, L. C., Hopwood, C. J., Gunderson, J. G., Skodol, A. E., Shea, M. T., Yen, S., . . .

McGlashan, T. H. (2007). Comparison of alternative models for personality disorders.

Psychol.Med., 37(7), 983-994.

Morey, L. C., Hopwood, C. J., Markowitz, J. C., Gunderson, J. G., Grilo, C. M., McGlashan,

T. H., . . . Skodol, A. E. (2012). Comparison of alternative models for personality

disorders, II: 6-, 8- and 10-year follow-up. Psychol Med, 42(8), 1705-1713. doi:

10.1017/s0033291711002601

Mundt, J. C., Marks, I. M., Shear, M. K., & Greist, J. H. (2002). The Work and Social

Adjustment Scale: a simple measure of impairment in functioning. Br.J.Psychiatry,

180, 461-464.

Muthén, B., & Muthén, L. (2012). Mplus Version 7: User’s guide. Los Angeles, CA: Muthén

& Muthén.

Nakash-Eisikovits, O., Dutra, L., & Westen, D. (2002). Relationship between attachment

patterns and personality pathology in adolescents. Journal of the American Academy

of Child and Adolescent Psychiatry, 41(9), 1111-1123.

Nederlof, E., Van der Ham, J. M., Dingemans, P. M., & Oei, T. I. (2010). The relation

between dimensions of normal and pathological personality and childhood

maltreatment in incarcerated boys. J.Pers.Disord., 24(6), 746-762. doi:

10.1521/pedi.2010.24.6.746 [doi];10.1521/pedi.2010.24.6.746 [pii]

Nicolo, G., Semerari, A., Lysaker, P. H., Dimaggio, G., Conti, L., D'Angerio, S., . . .

Carcione, A. (2011). Alexithymia in personality disorders: correlations with symptoms

and interpersonal functioning. Psychiatry Res, 190(1), 37-42. doi:

10.1016/j.psychres.2010.07.046
 101

Nordahl, H. M., & Stiles, T. C. (1997). Perceptions of parental bonding in patients with

various personality disorders, lifetime depressive disorders, and healthy controls.

J.Pers.Disord., 11(4), 391-402.

Olsson, I., & Dahl, A. A. (2012). Avoidant personality problems--their association with

somatic and mental health, lifestyle, and social network. A community-based study.

Compr Psychiatry, 53(6), 813-821. doi: 10.1016/j.comppsych.2011.10.007

Olsson, I., Sorebo, O., & Dahl, A. A. (2010). The Norwegian version of the Experiences in

Close Relationships measure of adult attachment: Psychometric properties and

normative data. Nord J Psychiatry, 64(5), 340-349. doi:

http://dx.doi.org/10.3109/08039481003728586

Olssøn, I., & Dahl, A. A. (2014). Comparison of patterns and strength of adult attachment in

patients with Axis I, Axis I+ II disorders and a community sample. Nord J Psychiatry,

68(7), 464-471.

Parker, G. (1989). The Parental Bonding Instrument: psychometric properties reviewed.

Psychiatr.Dev., 7(4), 317-335.

Parker, G., Tupling, H., & Brown, L. (1979). A parental bonding instrument. British Journal

of Medical Psychology, 52(1), 1-10. doi: http://dx.doi.org/10.1111/j.2044-

8341.1979.tb02487.x

Pedersen, G., Karterud, S., Hummelen, B., & Wilberg, T. (2013). The impact of extended

longitudinal observation on the assessment of personality disorders. Personality and

Mental Health, 7(4), 277-287.

Pedersen, G. A. (2002). Revised Norwegian version of Inventory of Interpersonal Problems -

Circumplex (IIP-C). Tidsskrift for Norsk Psykologforening, 39, 25-34.

 102

Perugi, G., Fornaro, M., & Akiskal, H. S. (2011). Are atypical depression, borderline

personality disorder and bipolar II disorder overlapping manifestations of a common

cyclothymic diathesis? World Psychiatry, 10(1), 45-51.

Perugi, G., Nassini, S., Maremmani, I., Madaro, D., Toni, C., Simonini, E., & Akiskal, H. S.

(2001). Putative clinical subtypes of social phobia: a factor-analytical study. Acta

Psychiatrica Scandinavica, 104(4), 280-288.

Popolo, R., Lysaker, P. H., Salvatore, G., Montano, A., Buonocore, L., Sirri, L., . . .

Dimaggio, G. (2014). Emotional inhibition in personality disorders. Psychother

Psychosom, 83(6), 377-378. doi: 10.1159/000365110

Posner, M. I., & Rothbart, M. K. (2000). Develpoing mechanisms of self-regulation.

Development and Psychopathology, 12(3), 427-441.

Prior, M., Smart, D., Sanson, A., & Oberklaid, F. (2000). Does shy-inhibited temperament in

childhood lead to anxiety problems in adolescence? J.Am.Acad.Child

Adolesc.Psychiatry, 39(4), 461-468. doi: S0890-8567(09)66189-X

[pii];10.1097/00004583-200004000-00015 [doi]

Ralevski, E., Sanislow, C. A., Grilo, C. M., Skodol, A. E., Gunderson, J. G., Shea, M. T., . . .

McGlashan, T. H. (2005). Avoidant personality disorder and social phobia: distinct

enough to be separate disorders? Acta Psychiatrica Scandinavica, 112(3), 208-214.

Ravindran, L. N., & Stein, M. B. (2010). The pharmacologic treatment of anxiety disorders: a

review of progress. J Clin Psychiatry, 71(7), 839-854. doi: 10.4088/JCP.10r06218blu

Reich, J. (2000). The relationship of social phobia to avoidant personality disorder: a proposal

to reclassify avoidant personality disorder based on clinical empirical findings.

European Psychiatry, 15(3), 151-159.

 103

Reich, J. (2014). Avoidant Personality Disorder and its Relationship to Social Phobia. In P.

M. Hofmann S.G. & DiBartolo (Ed.), Social Anxiety; Clinical, Developmental, and

Social Perspectives (pp. 27-41). New York: Elsevier.

Reichborn-Kjennerud, T., Czajkowski, N., Torgersen, S., Neale, M. C., Orstavik, R. E.,

Tambs, K., & Kendler, K. S. (2007). The relationship between avoidant personality

disorder and social phobia: a population-based twin study. Am.J.Psychiatry, 164(11),

1722-1728.

Reti, I. M., Samuels, J. F., Eaton, W. W., Bienvenu, O. J., III, Costa, P. T., Jr., & Nestadt, G.

(2002). Adult antisocial personality traits are associated with experiences of low

parental care and maternal overprotection. Acta Psychiatr.Scand., 106(2), 126-133.

doi: 2o305 [pii]

Rettew, D. C. (2000). Avoidant personality disorder, generalized social phobia, and shyness:

Putting the personality back into personality disorders. Harvard Review of Psychiatry,

8(6), 283-297.

Rettew, D. C., Zanarini, M. C., Yen, S., Grilo, C. M., Skodol, A. E., Shea, M. T., . . .

Gunderson, J. G. (2003). Childhood antecedents of avoidant personality disorder: a

retrospective study. Journal of the American Academy of Child & Adolescent

Psychiatry.42(9):1122-30,.

Rey, J. M., Bird, K. D., Kopec-Schrader, E., & Richards, I. N. (1993). Effects of gender, age

and diagnosis on perceived parental care and protection in adolescents. Acta

Psychiatr.Scand., 88(6), 440-446.

Rey, J. M., & Plapp, J. M. (1990). Quality of perceived parenting in oppositional and conduct

disordered adolescents. Journal of the American Academy of Child & Adolescent

Psychiatry, 29(3), 382-385.

 104

Riggs, S. A., Paulson, A., Tunnell, E., Sahl, G., Atkison, H., & Ross, C. A. (2007).

Attachment, personality, and psychopathology among adult inpatients: Self-reported

romantic attachment style versus Adult Attachment Interview states of mind.

Development and Psychopathology, 19(01), 263-291.

Rindal, G. (2000). Maskespill, tilknytningsmønster hos pasienter med unnvikende

personlighetsforstyrrelse. Oslo: Universitetet i Oslo.

Rodebaugh, T. L. (2009). Social phobia and perceived friendship quality. Journal of Anxiety

Disorders, 23(7), 872-878.

Rodebaugh, T. L., Gianoli, M. O., Turkheimer, E., & Oltmanns, T. F. (2010). The

interpersonal problems of the socially avoidant: Self and peer shared variance. Journal

of Abnormal Psychology, 119(2), 331-340. doi: http://dx.doi.org/10.1037/a0019031

Roisman, G. I., Holland, A., Fortuna, K., Fraley, R. C., Clausell, E., & Clarke, A. (2007). The

Adult Attachment Interview and self-reports of attachment style: an empirical

rapprochement. Journal of Personality and Social Psychology, 92(4), 678.

Rothbart, M. K., Ahadi, S. A., & Evans, D. E. (2000). Temperament and personality: origins

and outcomes. J Pers.Soc.Psychol., 78(1), 122-135.

Rothbart, M. K., & Derryberry, D. (2002). Temperament in children. In C. von Hofsten & L.

Bäckman (Eds.), Psychology at the turn of the millennium, vol.2: Social,

developmental, and clinical perspectives (2 ed., pp. 17-35). East Sussex, UK:

Psychology Press.

Russell, J., Kopec‐Schrader, E., Rey, J. M., & Beumont, P. (1992). The Parental Bonding

Instrument in adolescent patients with anorexia nervosa. Acta Psychiatrica

Scandinavica, 86(3), 236-239.

Satorra, A., & Bentler, P. M. (2001). A scaled difference chi-square test statistic for moment

structure analysis. psychometrika, 66(4), 507-514.

 105

Schmidt, N. B., Joiner Jr, T. E., Young, J. E., & Telch, M. J. (1995). The Schema

Questionnaire: Investigation of psychometric properties and the hierarchical structure

of a measure of maladaptive schemas. Cognitive Therapy and Research, 19(3), 295-

321.

Schneider, F. R., Stein, M. B., & Hermann, R. (2015). Social anxiety disorder: Epidemiology,

clinical manifestations, and diagnosis. http://www.uptodate.com, June 18Th

Schneier, F. R., Foose, T. E., Hasin, D. S., Heimberg, R. G., Liu, S. M., Grant, B. F., &

Blanco, C. (2010). Social anxiety disorder and alcohol use disorder co-morbidity in

the National Epidemiologic Survey on Alcohol and Related Conditions. Psychol Med,

40(6), 977-988. doi: 10.1017/s0033291709991231

Schoenleber, M., & Berenbaum, H. (2012). Aversion and proneness to shame in self-and

informant-reported personality disorder symptoms. Personality Disorders: Theory,

Research, and Treatment, 3(3), 294.

Schreiber, F., Bohn, C., Aderka, I. M., Stangier, U., & Steil, R. (2012). Discrepancies

between implicit and explicit self-esteem among adolescents with social anxiety

disorder. Journal of behavior therapy and experimental psychiatry, 43(4), 1074-1081.

Seemuller, F., Meier, S., Obermeier, M., Musil, R., Bauer, M., Adli, M., . . . Moller, H. J.

(2014). Three-Year long-term outcome of 458 naturalistically treated inpatients with

major depressive episode: severe relapse rates and risk factors. Eur Arch Psychiatry

Clin Neurosci, 264(7), 567-575. doi: 10.1007/s00406-014-0495-7

Semerari, A., Colle, L., Pellecchia, G., Buccione, I., Carcione, A., Dimaggio, G., . . . Pedone,

R. (2014). Metacognitive dysfunctions in personality disorders: correlations with

disorder severity and personality styles. J Pers Disord, 28(6), 751-766. doi:

10.1521/pedi_2014_28_137
 106

Sheehan, D. V., & Lecrubier, Y. (1994). Mini International Neuropsychiatric Interview

(M.I.N.I.). Tampa, Florida / Paris, France: University of South Florida Institutt for

Research in Psychiatry and INSERM-Hôpital de la Salpétrière.

Sheldon, A. E., & West, M. (1990). Attachment pathology and low social skills in avoidant

personality disorder: an exploratory study. Can J Psychiatry, 35(7), 596-599.

Simpson, J. A. (1990). Influence of attachment styles on romantic relationships. Journal of

Personality and Social Psychology, 59(5), 971.

Skodol, A. E. (2008). Longitudinal course and outcome of personality disorders. Psychiatr

Clin North Am, 31(3), 495-503, viii. doi: 10.1016/j.psc.2008.03.010

Skodol, A. E., Bender, D. S., Morey, L. C., Clark, L. A., Oldham, J. M., Alarcon, R. D., . . .

Siever, L. J. (2011). Personality Disorder Types Proposed for DSM-5. J.Pers.Disord.,

25(2), 136-169. doi: 10.1521/pedi.2011.25.2.136 [doi];10.1521/pedi.2011.25.2.136

[pii]

Skodol, A. E., Geier, T., Grant, B. F., & Hasin, D. S. (2014). Personality disorders and the

persistence of anxiety disorders in a nationally representative sample. Depression and

Anxiety, 31(9), 721-728.

Skodol, A. E., Gunderson, J. G., McGlashan, T. H., Dyck, I. R., Stout, R. L., Bender, D. S., . .

. Oldham, J. M. (2002). Functional impairment in patients with schizotypal,

borderline, avoidant, or obsessive-compulsive personality disorder. American Journal

of Psychiatry.159(2):276-83.

Soeteman, D. I., Hakkaart-van, R. L., Verheul, R., & Busschbach, J. J. (2008). The economic

burden of personality disorders in mental health care. J.Clin.Psychiatry, 69(2), 259-

265.

Sparrevohn, R. M., & Rapee, R. M. (2009). Self-disclosure, emotional expression and

intimacy within romantic relationships of people with social phobia. Behaviour

 107

Research and Therapy, 47(12), 1074-1078. doi:

http://dx.doi.org/10.1016/j.brat.2009.07.016

Spitzer, R. L. (1983). Psychiatric diagnosis: are clinicians still necessary? Compr.Psychiatry,

24(5), 399-411.

Stangier, U., Heidenreich, T., Peitz, M., Lauterbach, W., & Clark, D. (2003). Cognitive

therapy for social phobia: individual versus group treatment. Behaviour Research and

Therapy, 41(9), 991-1007.

Steiger, J. H. (1990). Structural model equation and modification: An internal estimation

approach. Multivariate Behavioral Research, 25, 173-180.

Stein, D. J., Ipser, J. C., & Balkom, A. J. (2004). Pharmacotherapy for social phobia.

Cochrane Database Syst Rev(4), Cd001206. doi: 10.1002/14651858.CD001206.pub2

Stein, D. J., Ruscio, A. M., Lee, S., Petukhova, M., Alonso, J., Andrade, L. H., . . . Kessler, R.

C. (2010). Subtyping social anxiety disorder in developed and developing countries.

Depress Anxiety, 27(4), 390-403. doi: 10.1002/da.20639

Stein, M. B., Roy-Byrne, P. P., & Hermann, R. (2015). Pharmachotherapy for social anxiety

disorder. http://www.uptodate.com, June 18Th

Steinert, C., Hofmann, M., Leichsenring, F., & Kruse, J. (2013). What do we know today

about the prospective long-term course of social anxiety disorder? A systematic

literature review. Journal of Anxiety Disorders, 27(7), 692-702.

Stravynski, A., Elie, R., & Franche, R. L. (1989). Perception of early parenting by patients

diagnosed avoidant personality disorder: a test of the overprotection hypothesis. Acta

Psychiatr.Scand., 80(5), 415-420.

Stravynski, A., Lesage, A., Marcouiller, M., & Elie, R. (1989). A test of the therapeutic

mechanism in social skills training with avoidant personality disorder. The Journal of

Nervous and Mental Disease, 177(12), 739-744.

 108

Svartberg, M., Stiles, T., & Seltzer, M. (2004). Effectiveness of short-term dynamic

psychotherapy and cognitive therapy for Cluster C personality disorders: A

randomized controlled trial. American Journal of Psychiatry, 161, 810-817.

Taylor, C. T., Laposa, J. M., & Alden, L. E. (2004). Is avoidant personality disorder more

than just social avoidance? J Pers Disord, 186(6), 571-594.

Taylor, G. J. (2000). Recent developments in alexithymia theory and research. The Canadian

Journal of Psychiatry/La Revue canadienne de psychiatrie.

Tempe, A. Z. (1992). The Walmyr Assesment Scale Scoring Manual: Walmyr Publishing Co.

Thomas, C., Turkheimer, E., & Oltmanns, T. F. (2003). Factorial structure of pathological

personality as evaluated by peers. Journal of Abnormal Psychology, 112(1), 81.

Tiliopoulos, N., & Jiang, Y. (2012). the empirical (ir)relevance of attachment theory.

ACPARIAN(4), 14-23.

Torgersen, S., & Alnaes, R. (1992). Differential perception of parental bonding in schizotypal

and borderline personality disorder patients. Compr.Psychiatry, 33(1), 34-38. doi:

0010-440X(92)90076-3 [pii]

Torgersen, S., Kringlen, E., & Cramer, V. (2001). The prevalence of personality disorders in a

community sample. Archives of General Psychiatry., 58(6), 590-596.

Treboux, D., Crowell, J. A., & Waters, E. (2004). When" new" meets" old": configurations of

adult attachment representations and their implications for marital functioning.

Developmental Psychology, 40(2), 295.

Trull, T. J., & Widiger, T. A. (2013). Dimensional models of personality: the five-factor

model and the DSM-5. Dialogues in Clinical Neuroscience, 15(2), 135.

Tucker, L. R., & Lewis, C. (1973). A reliability coefficient for maximum likelihood factor

analysis. psychometrika, 38(1), 1-10.

 109

Verheul, R., Bartak, A., & Widiger, T. (2007). Prevalence and construct validity of

personality not otherwise specified (PDNOS). Journal of Personality Disorders.,

21(4), 359-370.

Vogel, D. L., & Wei, M. (2005). Adult Attachment and Help-Seeking Intent: The Mediating

Roles of Psychological Distress and Perceived Social Support. Journal of Counseling

Psychology, 52(3), 347.

Vrabel, K. R., Hoffart, A., Ro, O., Martinsen, E. W., & Rosenvinge, J. H. (2010). Co-

occurrence of avoidant personality disorder and child sexual abuse predicts poor

outcome in long-standing eating disorder. J.Abnorm.Psychol., 119(3), 623-629.

Vriends, N., Bolt, O., & Kunz, S. (2014). Social anxiety disorder, a lifelong disorder? A

review of the spontaneous remission and its predictors. Acta Psychiatrica

Scandinavica, 130(2), 109-122.

Warren, S. L., Huston, L., Egeland, B., & Sroufe, L. (1997). Child and adolescent anxiety

disorders and early attachment. Journal of the American Academy of Child &

Adolescent Psychiatry, 36(5), 637-644.

Wei, M., Mallinckrodt, B., Larson, L. M., & Zakalik, R. A. (2005). Adult Attachment,

Depressive Symptoms, and Validation From Self Versus Others. Journal of

Counseling Psychology, 52(3), 368.

Wei, M., Russell, D. W., Mallinckrodt, B., & Vogel, D. L. (2007). The Experiences in Close

Relationship Scale (ECR)-short form: Reliability, validity, and factor structure.

Journal of Personality Assessment, 88(2), 187-204. doi:

http://dx.doi.org/10.1080/00223890701268041

Wei, M., Russell, D. W., Mallinckrodt, B., & Zakalik, R. A. (2004). Cultural Equivalence of

Adult Attachment Across Four Ethnic Groups: Factor Structure, Structured Means,

and Associations With Negative Mood. Journal of Counseling Psychology, 51(4), 408.
 110

Westen, D., Nakash, O., Thomas, C., & Bradley, R. (2006). Clinical assessment of attachment

patterns and personality disorder in adolescents and adults. Journal of Consulting and

Clinical Psychology, 74(6), 1065.

Widom, C. S., & Morris, S. (1997). Accuracy of adult recollections of childhood

victimization, part 2: childhood sexual abuse. Psychological Assessment, 9(1), 34.

Widom, C. S., & Shepard, R. L. (1996). Accuracy of adult recollections of childhood

victimization: Part 1. Childhood physical abuse. Psychological Assessment, 8(4), 412.

Wilberg, T., Karterud, S., Pedersen, G., & Urnes, O. (2009). The impact of avoidant

personality disorder on psychosocial impairment is substantial. Nord.J.Psychiatry, 1-7.

doi: 910019117 [pii];10.1080/08039480902831322 [doi]

Williams, L. M. (1994). Recall of childhood trauma: A prospective study of women's

memories of child sexual abuse. Consulting and Clinical Psychology.

Winnicott, D. W. (1956). Collected papers. London: Travistock.

World Health Organization. (1978). International Classification of Diseases (9 ed.). Geneva:

WHO.

World Health Organization. (1993). The ICD-10 (International Statistical Classification of

Diseases) Classification of Mental and Behavioural Disorders. Geneva: WHO.

Yang, M., Coid, J., & Tyrer, P. (2010). Personality pathology recorded by severity: national

survey. The British Journal of Psychiatry, 197(3), 193-199.

Ye, G., Yao, F. M., Fu, W. Q., & Kong, M. (2011). The relationships of self-esteem and affect

of university students with avoidant personality disorder. Chinese Mental Health

Journal, 25(2), 141-145.

Yen, S., Shea, M. T., Battle, C. L., Johnson, D. M., Zlotnick, C., Dolan-Sewell, R., . . .

McGlashan, T. H. (2002). Traumatic exposure and posttraumatic stress disorder in

borderline, schizotypal, avoidant, and obsessive-compulsive personality disorders:

 111

findings from the collaborative longitudinal personality disorders study. Journal of

Nervous & Mental Disease.(8), 510-518.

Young, J. E. (1990). Cognitive therapy for personality disorders: A schema-focused

approach. Sarasota, FL, England: Professional Resource Exchange, Inc; England.

Zanarini, M. C., Frankenburg, F. R., Reich, D. B., Conkey, L. C., & Fitzmaurice, G. M.

(2015). Treatment rates for patients with borderline personality disorder and other

personality disorders: a 16-year study. Psychiatr Serv, 66(1), 15-20. doi:

10.1176/appi.ps.201400055

Zhang, T., Chow, A., Wang, L., Dai, Y., & Xiao, Z. (2012). Role of childhood traumatic

experience in personality disorders in China. Compr.Psychiatry, 53(6), 829-836. doi:

S0010-440X(11)00200-8 [pii];10.1016/j.comppsych.2011.10.004 [doi]

Zimmermann, P., Alliger-Horn, C., Kowalski, J. T., Plate, S., Wallner, F., Wolff, E., &

Strohle, A. (2013). Treatment of avoidant personality traits in a German Armed Forces

inpatient psychiatric setting. Military Medicine, 178(2), 213-217.

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Table 1: DSM-IV defines Avoidant Personality Disorder as meeting four or more of the following criteria:

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 engage in any new activities because they may prove embarrassing
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Table 2: DSM-IV inclusion criteria for Social Phobia

A. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible

scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will lead to humiliation or

embarrassment.

B. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally

predisposed panic attack.

C. The person recognizes that the fear is excessive or unreasonable.

D. The feared social or performance situations are avoided or else are endured with intense anxiety or distress.

E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person’s normal

routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress having the phobia.
 114

Table 3. Personality Functioning, according to DSM-5 AMPD

SELF
Identity Self-Direction
Has ongoing awareness of a Sets and aspires to reasonable
unique self; maintains role- goals on a realistic assessment
appropriate boundaries of personal capacities
INTERPERSONAL
Empathy Intimacy
Is capable of accurately
understanding others’ Maintains multiple satisfying
experiences and motivations in and enduring relationships in
most situations personal and community life

Has consistent and self- Utilizes appropriate standards of Comprehends and appreciates Desires and engages in a number
regulated positive self-esteem, behavior, attaining fulfillment in others’ perspectives, even if of caring, close, and reciprocal
with accurate self-appraisal multiple realms disagreeing relationships

Is capable of experiencing, Can reflect on, and make Is aware of the effect of own Strives for cooperation and
tolerating, and regulating a full constructive meaning of, actions on others mutual benefit and flexibly
range of emotions internal experience responds to a range of others’
ideas, emotions, and behaviors
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Table 4. Sociodemographic characteristics of the patients with Social Phobia (SP) without Avoidant Personality Disorder (AvPD); Pure-SP
group; AvPD without SP, Pure-AvPD group; and the AvPD+SP group

Pure-SP Pure-AvPD SP+AvPD F/ χ² Group

n=20 n=15 n=56 difference
Mean (SD) Mean (SD) Mean (SD)

Sex (% female) 50 53 73 4.53 ns

Age (years) 38.4 (12.6) 42.47 (9.6) 36.04 (9.0) 2.53 ns
Married/cohabiting (%) 50 47 38 0.985 ns
Education after jr secondary school (y) 4.4 (3.0) 3.8 (3.0) 4.0 (3.3) 0.143 ns
Age at first contact psych. services (y) 26.7 (9.1) 26.9 (9.3) 27.0 (10.8) 0.006 ns
Quality of life 3.9 (1.4) 3.7 (1.4) 3.9 (1.5) 0.066 ns
50–100% occupation (%) 60 40 26 7.49 SP*> SP+AvPD

*Pearson Chi-squared, p<0.01, eta²=0.32

116
I
II
 RESEARCH ARTICLE

Avoidant Personality Disorder versus Social

Phobia: The Significance of Childhood
Neglect
Ingeborg Eikenaes1☯*, Jens Egeland2☯, Benjamin Hummelen3☯, Theresa Wilberg4☯
1 Department of Group Psychotherapy, Division of Mental Health and Addiction, Vestfold Hospital Trust,
Tønsberg, Norway, 2 Department of Research, Division of Mental Health and Addiction, Vestfold Hospital
Trust, Tønsberg, Norway, 3 Department of Research and Development, Division of Mental Health and
Addiction, Oslo University Hospital, Oslo, Norway, 4 Department for Research and Development, Division of
Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
a11111
☯ These authors contributed equally to this work.
* ingeborg.eikenes@siv.no

Abstract
OPEN ACCESS
Objectives
Citation: Eikenaes I, Egeland J, Hummelen B,
Wilberg T (2015) Avoidant Personality Disorder Avoidant personality disorder (AvPD) and social phobia (SP) are common disorders both in
versus Social Phobia: The Significance of Childhood the community and in clinical settings. Whether the two disorders represent different severi-
Neglect. PLoS ONE 10(3): e0122846. doi:10.1371/
ty levels of social anxiety disorder is currently in dispute. The relationship between AvPD
journal.pone.0122846
and SP is probably more complex than previously assumed. Several environmental, tem-
Academic Editor: Valsamma Eapen, University of
peramental, and constitutional factors may play a role in the etiology of AvPD and SP. Better
New South Wales, AUSTRALIA
knowledge about childhood experiences may shed light on similarities and differences be-
Received: November 18, 2014
tween the two disorders. The aim of this study was to compare self-reported childhood ex-
Accepted: February 19, 2015 periences in AvPD and SP patients.
Published: March 27, 2015

Copyright: © 2015 Eikenaes et al. This is an open Design

access article distributed under the terms of the This is a cross-sectional multi-site study of 91 adult patients with AvPD and/ or SP. We com-
Creative Commons Attribution License, which permits
pared patients with AvPD with and without SP (AvPD group) to patients with SP without
unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are AvPD (SP group).
credited.

Data Availability Statement: Patient anonymity was Methods

a main issue when this project was accepted by the
The patients were examined using structured diagnostic interviews and self-report mea-
Regional Medical Ethics Committee. There are no
names or easily identifiable personal information in sures, including Child Trauma Questionnaire, Parental Bonding Instrument, and Adult Tem-
the electronic data-file. However, by combining perament Questionnaire.
information such as gender, age with treatment
information it is possible to identify individuals. Thus,
one condition for being allowed to make this data-
Results
registry was that it should be kept inaccessible to Both AvPD and SP were associated with negative childhood experiences. AvPD patients
outsiders with the same degree of security as patient
reported more severe childhood neglect than patients with SP, most pronounced for physi-
files. Thus, the authors are not allowed to publish the
datafile as supporting information. The data file is not cal neglect. The difference between the disorders in neglect remained significant after con-
the unique property of the main researcher, but is trolling for temperamental factors and concurrent abuse.

PLOS ONE | DOI:10.1371/journal.pone.0122846 March 27, 2015 1 / 14

 Avoidant PD and Childhood Neglect

kept in a Research Data-server owned by the Conclusions

hospital. The authors will be able to grant access to
the data upon request. Requests should be sent to The study indicates that childhood neglect is a risk factor for AvPD and may be one contrib-
the person in charge of information security in the uting factor to phenomenological differences between AvPD and SP.
authors' hospital by e-mail to
Informasjonssikkerhetsansvarlig@siv.no.

Funding: This work was supported by the Vestfold

Hospital Trust. The funder had no role in study
design, data collection and analysis, decision to
publish, or preparation of the manuscript.
Competing Interests: The authors have declared
that no competing interests exist.
Introduction
Avoidant personality disorder (AvPD) and Social phobia (SP) are common disorders both in
the general population and in clinical settings [1–5]. There is an ongoing debate regarding
whether AvPD and SP are different disorders, or just reflect different degrees of severities of so-
cial anxiety disorder (SAD) [6–10]. The introduction of the diagnostic specifier generalized SP
(GSP) in the revised third edition of the Diagnostic and Statistical Manual for Mental Disorders
(DSM-III-R) [11], defining GSP as fears in most social situations, has brought the diagnostic
constructs even closer together. A vulnerable temperament combined with early environmental
risk factors are suggested etiological factors in the development of both AvPD and SP [12–14].
In a large study of female twins Reichborn-Kjennerud et al. [15] found that AvPD and SP were
influenced by the same genetic factors, while the environmental factors influencing the two dis-
orders were uncorrelated and unique to each disorder. So far, however, our knowledge of envi-
ronmental influences associated with the two disorders is sparse. We wanted to compare self-
reported childhood experiences for patients with AvPD and SP to shed further light on the re-
lationship between the two disorders.
In the DSM-IV [16] AvPD is defined as a pervasive pattern across time and situations, start-
ing in early adulthood, and characterized by social inhibition, feeling of inadequacy and hyper-
sensitivity to negative evaluation, indicated by at least four of seven explicit criteria (Table 1).
Social Phobia is defined as a marked and enduring anxiety for one or more social situations in
which the person is exposed to or observed by unknown people. The person fears to do some-
thing or behave in a way that will be humiliating or embarrassing, and avoids the situations, or
endures the situations with intense anxiety or distress. AvPD has primarily been studied in
samples of SP [10]. These studies have documented a quantitative severity continuum with an
increasing gradient of symptoms and psychosocial dysfunctioning from simple SP, via GSP to
GSP with AvPD. Based on these findings a continuum hypothesis has been proposed, suggest-
ing that SP and AvPD represent different conceptualizations of the same disorder, merely dif-
fering in degree of severity [10]. Only few studies have included a “pure” AvPD group without
SP [1, 2, 17]. The discussion whether AvPD and SP is the same disorder, is part of a larger de-
bate of the relationship between clinical disorders on Axis I and PDs on Axis II, see Kreuger,
2005 [18] and Dimaggio et al 2013 [19]. The discussion parallels the debate on schizophrenia-

Table 1. DSM-IV diagnostic criteria for AvPD.

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 engage in any new activities because they may prove embarrassing
doi:10.1371/journal.pone.0122846.t001

PLOS ONE | DOI:10.1371/journal.pone.0122846 March 27, 2015 2 / 14

 Avoidant PD and Childhood Neglect

like symptoms, affective instability, impulsivity and depressive symptoms across Axis I and II,
for instance the proposal to categorize Borderline PD as a bipolar spectrum disorder [20, 21].
In a review of environmental risk factors for SAD, Brook & Schmidt [12] found studies of
four areas: parenting and family environment, adverse life events, socioeconomic status and
culture, and gender. The authors conclude that “research has successfully correlated parenting
as a small but integral part of the mechanism in developing SAD”, and points to an interrelated
multi-faceted process of environmental risk and resilience factors in development of the disor-
der [12]. More recently in the study of Kuo, Goldin, Werner, Heimberg, & Gross [22] individu-
als with GSP reported greater childhood emotional abuse and neglect, but not more sexual
abuse, physical abuse, or physical neglect, compared with healthy controls, pointing to the less
dramatic and more subtle maltreatment as a possible risk factor in the development of GSP.
Like for most studies of SP or SAD, co-morbidity with AvPD was not controlled for. Moreover,
like most studies on childhood trauma, the relative contribution of neglect and abuse was not
investigated. We wanted to elaborate on these findings, by including AvPD and examine the
relative contribution of abuse and neglect, and even temperament.
Childhood trauma and parental maltreatment are also well documented as risk factors for
adult PD in general, in both prospective and retrospective studies [23–26]. Johnsen et al. [24]
found that individuals with documented childhood abuse or neglect were four times as likely
as those who were not abused or neglected, to be diagnosed with PDs during early adulthood.
Childhood emotional neglect was associated with increased risk of several PDs, including
AvPD [27].
So far, few studies have focused specifically on AvPD and childhood experiences. However,
in a large clinical study Rettew et al. [28] found that patients with AvPD reported more physi-
cal and emotional abuse during childhood compared to patients with major depression, but
this result was influenced by comorbid diagnoses. In a large outpatient sample in Shanghai,
self-reported experience of childhood emotional neglect was associated with adult cluster C
PDs (avoidant, dependent, and obsessive-compulsive PD) [26]. Joyce et al. [13] found that self-
reported childhood neglect predicted AvPD in a sample of depressed outpatients. Moreover, in
an early, small retrospective study, Arbel and Stravynski [29] found that the main features dif-
ferentiating adult AvPD patients from healthy controls were the perception of a discouraging
home climate with less parental demonstration of love and pride in the child, and a perception
of their parents as shaming, guilt-engendering, and intolerant.
Abuse refers to maltreatment, harmful behavior, and non-accidental injury from an adult
person directed toward the child, while neglect refers to the failure of caretakers to provide a
child’s basic psychological or physical needs [30]. Generally, childhood neglect has received
less empirical attention than childhood abuse [31]. In clinical settings the experience of neglect
in childhood may be overshadowed by dramatic histories of maltreatment and abuse. However,
parental abuse and neglect can co-occur in dysfunctional families, making it difficult to disen-
tangle specific consequences of the various types of maltreatment that the child may suffer
[32]. At present little is known about the unique contribution of neglect to adult psychopathol-
ogy more generally, and to AvPD as compared with SP specifically.
Parental behavior has also been studied with the Parental Bonding Instrument (PBI) [33],
which aims to collect relevant retrospective information of childhood experiences. A combina-
tion of low scores on the two subscales care and control is called the neglectful parenting pat-
tern, which was found to be the dominating pattern in a small sample of patients with AvPD
[34]. However, when Joyce et al. [13] found neglect to be associated with AvPD, they operatio-
nalized neglect as low scores on the care dimension only. A combination of low scores on the
care and high scores on the control subscales is called the cold control pattern, which has been

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 Avoidant PD and Childhood Neglect

associated with many kinds of adult psychopathology [35–37]. The cold control pattern might
also be among the risk factors for SAD [12, 38, 39].
Maltreatment probably interacts with temperamental factors to influence personality devel-
opment and risk of psychiatric symptoms [13]. Rothbart and Derryberry [40] define tempera-
ment as constitutionally based individual differences in emotional, motor, and attentional
reactivity and regulation. Temperament is influenced by experience, and in turn influences ex-
perience, and is gradually transformed and integrated into our adult personality [41]. Shyness
has been proposed as a temperamental trait in both SAD and AvPD. However, Prior, Smart,
Sanson, and Oberklaid [42] found only modest relation between childhood shyness and adoles-
cent anxiety disorder in a longitudinal, community study. Most shy children did not develop
an anxiety disorder, and most adolescents with anxiety disorders had not been especially shy.
Nevertheless, other studies of both epidemiological and clinical samples suggest that both
AvPD and SP are associated with the temperamental factor “behavioral inhibition”, which is
characterized by avoidance of strangers and novelty, shyness, heightened sensitivity and anxi-
ety reactivity [43–45]. Thus, these disorders seem to have some temperamental dispositions in
common, but temperamental manifestations could still be present in various degrees.
Taken together, some studies indicate that both AvPD and SP are associated with various
types of childhood maltreatment. Most notable, however, no studies have made a direct com-
parison of childhood environmental factors between the disorders.
In clinical samples, many patients with AvPD have a co-occurring SP diagnosis [10]. Also
in this sample the two diagnoses were concurrent in most patients. As we wanted to focus on
AvPD, we divided the patients into two diagnostic groups: patients with AvPD with or without
SP (the AvPD group) and patients with SP without AvPD (the SP group). This choice was sup-
ported by previous findings in a large clinical PD sample [17], partially by the results of an epi-
demiological study [1], as well as a previous study of the present sample [7] suggesting that SP
in subjects with AvPD does not add to the overall severity of the condition.
The aim of the present study was to investigate similarities and differences between the two
diagnostics groups in self-reported childhood experiences. Based on previous research we ex-
pected that 1) Patients in the AvPD group will report more severe childhood maltreatment
than patients in the SP group as assessed by CTQ. 2) We further explored the relationship be-
tween the diagnostic groups and childhood maltreatment when taking into account the pres-
ence of different trauma. 3) Moreover, we expected that the AvPD group will more often
report a neglectful parenting style compared with the SP group, measured by PBI, whereas the
groups will not differ in rates of a cold control parenting style. 4) Finally, we hypothesized that
differences in environmental factors will remain significant when controlling for temperament.

Methods
Settings
This cross-sectional multi-site study was conducted by the Vestfold Hospital Trust and includ-
ed 91 adult patients with AvPD and/or SP. Exclusion criteria were cluster A or B PDs, current
alcohol or substance dependence, psychotic disorders, bipolar I disorder, adult attention deficit
hyperactivity disorder (ADHD), pervasive development disorders (e.g., Asperger’s syndrome),
organic syndromes, and homelessness. Twenty-five of the included patients were selected
using baseline data from the Ullevål Personality Project (UPP) [46]. The other 66 patients were
recruited by their therapists, regardless of time in therapy, from seven treatment centers spe-
cialized in treating PDs or anxiety disorders. The recruitment of these patients was based on
the therapist’s diagnostic screening and evaluation, and inclusion was decided after the diag-
nostic research interviews. Seventy-two patients were recruited. Six patients were excluded: five

PLOS ONE | DOI:10.1371/journal.pone.0122846 March 27, 2015 4 / 14

 Avoidant PD and Childhood Neglect

because the research interviews revealed diagnoses of alcohol dependence (n = 2), adult ADHD
(n = 2), and borderline PD (n = 1); and one patient dropped out before completing the inter-
views. Study participation was voluntary, and all patients provided informed written consent
before inclusion. The study was approved by the Norwegian Social Science Data Service and
the Regional Committee for Medical Research Ethics.

Assessments
Axis I and axis II diagnoses. Axis I diagnoses were based on the Mini International Neu-
ropsychiatric Interview for Axis I diagnoses (MINI) [47]. The Structured Clinical Interview for
the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) was
used to assess personality disorders (SCID-II) [48]. Trained and experienced clinicians con-
ducted the interviews. All patients with SP were asked to describe examples of SP-related prob-
lems from their lives, which were used along with other information to evaluate whether they
had simple or generalized SP. All interviews were audiotaped. An independent, blind, and ex-
perienced psychiatrist rated the diagnostic interviews of 26 randomly selected patients. Al-
though there was 85% agreement regarding the presence or absence of SP, there were too few
patients without SP to compute Kappa for SP. Kappa for AVPD was 0.76. The intraclass corre-
lation (ICC 2.1) was 0.86 (95% CI: 0.71–0.93) for the number of avoidant criteria and 0.89
(95% CI: 0.75–0.95) for the total number of PD criteria, indicating satisfactory
diagnostic reliability.
Childhood trauma. Child trauma was assessed using the Childhood Trauma Question-
naire (CTQ) a 44-item self-report inventory that provides brief screening for histories of abuse
and neglect, and has shown good reliability and validity [49, 50]. Items are scored on a 5-point
Likert scale from 1 (never true) to 5 (very often true). Items scored are summed on 5 different
subscales: emotional, physical, and sexual abuse; and physical and emotional neglect. Emotion-
al abuse refers to verbal assaults on a child’s sense of worth or well-being, or any humiliating,
demeaning, or threatening behavior. Physical abuse includes descriptions of bodily assaults
that pose a risk of or result in injury. Sexual abuse describes sexual contact or conduct. Emo-
tional neglect refers to lack of love, encouragement, belonging, and support. Physical neglect re-
fers to lack of food, shelter, safety, supervision, and health. It is not unusual to underreport
childhood trauma [51] and CTQ therefore includes a 3-item denial/minimization scale to de-
tect false negative trauma reports. In this sample, eight patients scored on the denial scale. Still,
no differences were detected when data were analyzed with and without these eight patients.
The raw scores of the five CTQ subscales are not comparable and have different cut-off thresh-
olds. Raw scores were therefore converted into classifications of four levels of severity based on
validation studies in normal and psychopathological samples [30]: “absent to minimal” (level
1), “low to moderate” (level 2), “moderate to severe” (level 3), and “severe to extreme” (level 4).
We used these four levels of severity to harmonize the subscales. Thereby we were able to com-
pute a composite neglect score based on the average classification of severity (1–4) of emotional
and physical neglect. Likewise, we computed a composite abuse score from the three abuse sub-
scales: emotional abuse, physical abuse and sexual abuse. The correlation between physical and
emotional neglect was not significant. Emotional abuse correlated moderately with both physi-
cal (r = .443) and sexual abuse (r = .372) whereas the correlation between sexual and physical
abuse was non-significant. This led us to conclude that colinerality did not prohibit the con-
struction of the composite scores.
Perceived parental behavior. Perceived parental behavior was assessed by the 25-item Pa-
rental Bonding Instrument (PBI) self-report questionnaire [52]. The items are scored on a
5-point Likert scale from 1 (very likely) to 5 (very unlikely), based on perceived parental

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 Avoidant PD and Childhood Neglect

Fig 1. Attachment style in Avoidant personality disorder (AvPD, n = 70) and Social phobia (SP, n = 20). Distribution of the AvPD and SP groups in the
two dimensional, four categorical parental style model according to the Parental Bonding Instrument (PBI). ORIGO is defined as the cut-off scores, se text.
AvPD: Avoidant personality disorder, SP: Social phobia, M: Mother, F: Father
doi:10.1371/journal.pone.0122846.g001

behavior before the age of 16 years. Usually two subscales are computed for each parental fig-
ure: care/affection and overprotection/control. Combination of the two subscales generates
four parental styles: optimal bonding (high care, low overprotection); affectionate constraint
(high care, high overprotection); affectionless control, also called cold control (low care, high
overprotection); and neglectful parenting (low care, low overprotection). Cut-off scores for
high and low care and overprotection were computed based on normative data [33]. The re-
spective cut-off scores are 27 and 24 for maternal and paternal care, and 13.5 and 12.5 for ma-
ternal and paternal control. We used these cut-offs to compute the four patterns (Fig. 1).
Temperament. The short form of the Adult Temperament Questionnaire (ATQ) [41] was
used to assess temperament. The ATQ is a self-report questionnaire that consists of 77 items
rated on a 7-point Likert scale and includes four factor scales: effortful control, negative affect,
extraversion, and orienting sensitivity. Good internal consistency was reported in a sample of

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 Avoidant PD and Childhood Neglect

Table 2. Socio-demographic and clinical characteristics of patients with AvPDa (n = 71) and SPb
(n = 20).

AvPD SP t(df) or χ2(df) p

Female, % 69 50 2.47(1) 0.116
Age, years 37.4 (9.4) 38.4 (12.6) 0.33 (25) 0.743
Married/Cohabiting, % 40 50 0.64 (1) 0.452
Education after primary school, years 3.9 (3.3) 4.4 (3.0) 0.53 (88) 0.601
Age at first contact psych. services, years 26.9 (10.4) 26.7 (9.1) 0.11 (88) 0.910
Quality of life 3.9 (1.5) 3.9 (1.4) 0.15 (89) 0.883
50–100% Occupation, % 29 60 6.47 (1) 0.011
Number of symptom disorders 3.1 (1.12) 2.5 (.89) 2.22 (89) 0.029
Total number of PD criteria 12.5 (3.99) 6.8 (2.69) 7.55 (45.2) 0.000
Work and social adjustment score 24.2 (69) 19.1 (9.3) 2.68 (88) 0.009

Data are presented as mean (SD) unless otherwise noted.

a
The AvPD group comprised patients with AvPD with and without co-occurring SP.
b
The SP group comprised patients with SP without AvPD.

doi:10.1371/journal.pone.0122846.t002

258 undergraduate students, with Cronbach’s alpha of 0.78, 0.81, 0.75, and 0.85 for effortful
control, negative affect, extraversion, and orienting sensitivity, respectively [53]. The same level
of internal consistency was observed for the Norwegian version of the ATQ in the UPP sample,
with Cronbach’s alphas of 0.82 for effortful control, 0.81 for negative affect, 0.73 for extraver-
sion, and 0.81 for orienting sensitivity [Urnes et al., unpublished data].

Participants
The 91 patients had a mean age of 37.6 years (SD = 10.2); 65% were female, 44% were married
or cohabiting, and they had an average of four years of education after junior secondary school
(SD = 3.2). The mean age at first contact with psychiatric services was 26.9 years (SD = 10.1),
and the average time interval between the first contact and the present treatment was 12 years.
The sample was divided into two groups, the AvPD group (AvPD with and without SP; n = 71)
and the “pure” SP group (SP without AvPD; n = 20). Eighteen patients in the SP group (90%)
had generalized SP, two had simple SP. There were no differences in socio-demographic char-
acteristics between the two groups, except that only 29% of patients in the AvPD group were
working half-time or more, compared with 60% in the SP group (p = 0.011; Table 2). The
AvPD group also had more Axis I or “symptom disorders” (p = 0.029) and a greater number of
total PD criteria than the SP group (p < 0.001). More details are provided in a previous publi-
cation [7].

Statistics
Background demographic and clinical variables were analyzed using t-tests and the chi-squared
test for continuous and categorical variables, respectively. We compared the AvPD group and
the SP group, applying analysis of variance (ANOVA) for the continuous variables of the CTQ,
ATQ, and PBI. Because skewed distributions of the separate abuse subscales of the CTQ pre-
cluded the use of parametric methods, the Mann-Whitney-U test was used. To analyze the
unique contribution of the variables showing significant group differences in the ANOVAs, fol-
low-up covariance analyses (ANCOVAs) were performed controlling for the effects of these
possible confounding variables. We used Eta2 and r2 as measures of effect size for the normal

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 Avoidant PD and Childhood Neglect

and the skewed distributed data respectively. The alpha level was set at p < 0.05. Some statisti-
cally trends are reported due to the small sample size and risk of type II errors.

Results
In line with our first hypothesis, the AvPD group had significantly higher scores on physical
neglect, as well as on the composite neglect variable, compared with the SP group (p = 0.003
and p = 0.007), Table 3. Emotional neglect trended higher in the AvPD group (p = 0.061).
However, contrary to our expectations, there were no significant differences in emotional,
physical, or sexual abuse between the groups although there was a trend toward more abuse in
the AvPD group, measured by the more robust composite abuse variable (p = 0.069), Table 3.
Exploration of the relative contribution of neglect and abuse revealed that the AvPD-related
difference in the composite neglect remained significant when controlling for physical abuse
(F = 6.33, p = 0.014, Eta2 = 0.068), sexual abuse (F = 6.63, p = 0.012, Eta2 = 0.071), and emo-
tional abuse (F = 5.61, p = 0.020, Eta2 = 0.061) by ANCOVA (df: 2, 91). Each of the abuse vari-
ables was also significantly related to neglect: physical abuse (F = 9.20, p = 0.003, Eta2 = 0.096);
sexual abuse (F = 5.56, p = 0.021, Eta2 = 0.060); and emotional abuse (F = 29.45, p = 0.000,
Eta2 = 0.25).
Contrary to our hypothesis, there were no between-group differences in the distribution of
the four categories of parenting patterns of the PBI when analyzed by a Chi Square test of the 4

Table 3. Clinical Characteristics of Patients with AvPDa (n = 71) and SPb (n = 20).

AvPD SP P Effect size

Mean (SD)/ Mdn (I-R)e Mean (SD)/ Mdn (I-R)e Eta2/ r2 f
CTQc
Emotional abuse 11.00 (8) e 10.00 (6) e .144 .023 f
Physical abuse 5.00 (1) e 5.00 (1) e .668 .002 f
e e
Sexual abuse 6.00 (4) 5.50 (2) .354 .009 f
Composite Abuse Class d 1.9 (0.8) 1.6 (0.6) .069 .037
Emotional neglect 16.0 (4.2) 13.7 (5.2) .061 .039
Physical neglect 8.3 (3.2) 6.7 (1.6) .003 .050
Composite Neglect Class d 2.8 (0.7) 2.3 (0.7) .007 .081
PBI
Mother care 17.7 (9.5) 19.8 (7.7) .363 .010
Mother control 17.4 (7.8) 17.6 (8.7) .899 .000
Father care 14.9 (8.2) 16.2 (7.7) .568 .004
Father control 14.5 (7.4) 14.1 (5.9) .807 .001
ATQ
Negative Affect 4.9 (0.7) 4.4 (0.8) .010 .072
Extraversion 3.2 (0.8) 3.6 (0.9) .078 .034
Effortful Control 4.1 (0.8) 4.3 (0.7) .259 .014
Orienting sensitivity 4.3 (0.8) 4.2 (0.7) .484 .006
a
The AvPD group comprised patients with AvPD with and without co-occurring SP.
b
The SP group comprised patients with SP without AvPD.
c
Score range: 5 (no) to 25 (extreme),
d
Score range: 1 (none or minimal) to 4 (severe to extreme)
e
Mdn = Median; I-R = Interquartile Range,
f 2 p
r = (z / N) 2

doi:10.1371/journal.pone.0122846.t003

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 Avoidant PD and Childhood Neglect

x 2 table (Fig. 1). Neither were there any differences in the dimensional scales care nor control
between the groups. The great majority in both groups reported their parents to be low on care
(80% of mothers and 86% of fathers in the AvPD group, and 74% of mothers and 89% of fa-
thers in the SP group).
Scores on the ATQ factor negative affect were higher (p = 0.010) among patients in the
AvPD group, compared with the SP group and extroversion trended lower (p = 0.078) in the
AvPD group, Table 3. To determine whether difference in the composite neglect was signifi-
cant when controlling for these differences in temperament, we used the composite neglect
score as dependent variable: In agreement with the last hypothesis, the AvPD-related difference
in neglect remained significant when we controlled for the temperamental factors by
ANCOVA (df: 2, 91; controlling for extroversion: F = 6.99, p = 0.010, Eta2 = 0.074; controlling
for negative affect: F = 5.27, p = 0.024, Eta2 = 0.057). Neither extroversion nor negative affect
was significantly related covariates of the composite neglect score.

Discussion
The main finding of the present study was that AvPD was associated with more self-reported
neglect as compared with SP. This result is partially in agreement with retrospective findings
that emotional neglect was predictive of cluster C PDs [26] and prospective findings that it was
predictive of AvPD [27]. The difference between the diagnostic groups was most pronounced
for physical neglect, though. Notably, the AvPD-related difference in neglect remained signifi-
cant when we controlled for child abuse as well as temperamental differences. Thus, the results
suggest that the often less dramatic or silent maltreatment experiences of emotional and physi-
cal neglect might be risk factors for adult AvPD over and above the effects of both abuse experi-
ences and temperamental dispositions.
Neglect is generally defined as the absence of protection, care, and positive attention (i.e.,
the parents are physically present, but do not attend to the child). No doubt, neglect is poten-
tially a very harmful experience for a child and the psychological consequences are probably
manifold. From the child’s perspective, his or her physical and emotional needs may be per-
ceived as irrelevant or too much trouble for the parents. It is easy to understand that a child
who is not given attention, care, and protection within the attachment relationship might de-
velop assumptions that one is not of interest to others or not worthy of being loved. Corre-
spondingly, neglect may interfere with the child’s development of perceptions of others as safe
sources of comfort, support, and reassurance. Such experiences could be integrated in the per-
sonality as more permanently disturbed representations of self and others characteristic for
this form of personality pathology. In instances of more severe neglect even basic affect regula-
tion and self-coherence may be affected. Moreover, individuals with a negative self-image and
lack of interpersonal trust tend to relate to others in maladaptive ways. For example, they may
not ask for others opinions or involvement regarding their personal issues, because of expecta-
tions of others as not interested or critical to their needs. Also, close relationships may evoke
inherent negative self-views causing defensive avoidance of social contact. Others may inter-
pret this behavior as expressing no need or wish for their involvement, or even as arrogant, giv-
ing rise to even more interpersonal distance. Thus this interpersonal pattern may reinforce
itself in a vicious circle confirming their assumptions and increasing their loneliness.
The described patterns are in line with the self-other pattern described in the DSM-5 re-
garding AvPD [54]. According to the alternative model for PDs in DSM-5, Section III, a defec-
tive self as well as relational dysfunction is at the core of PDs [54, 55]. In a previous study of the
present sample, patients with AvPD exhibited more impairment in self and relational function-
ing than those with SP [7]. One hypothesis, then, is that different levels of childhood

PLOS ONE | DOI:10.1371/journal.pone.0122846 March 27, 2015 9 / 14

 Avoidant PD and Childhood Neglect

maltreatment is one of the factors underlying such differences in personality functioning. In

the presence of common constitutional dispositions for AvPD and SP [15], the experience of
more severe childhood neglect may be a factor that drives personality development towards
avoidant personality pathology [13]. It is important to recognize, however, that a child’s tem-
peramental make-up may have a bidirectional effect, i.e. exert a certain influence on the pa-
rents’ child-rearing behavior, and at the same time render the child more vulnerable to specific
responses from the caregivers. Maltreatment probably affects children differently, and interacts
with both constitutional and environmental risk and resilience factors. For example, tempera-
mental factors may render a person more vulnerable to developing AvPD or SP if they are ex-
posed to neglect or abuse, and also more at risk for being neglected or abused. Thus, the
pathways to specific disorders are complex and more studies are needed to increase our knowl-
edge of the relationship between childhood experiences, temperament, and personality dys-
functioning in subjects with AvPD and SP.
The severity level of the mean score for emotional neglect was in the moderate-to-severe
range in the AvPD group and in the low-to-moderate range in the SP group. For physical ne-
glect, the severity level was in the low-to-moderate range in the AvPD group and in the none-
to-minimal range in the SP group. Interestingly, based on visual comparison of our data with a
Spanish sample in which the CTQ was applied to patients with borderline PD (BPD), other
PDs, and non-psychotic axis I disorders [23], our AvPD group seems to have higher neglect
scores than the BPD group, and our SP group resembles the same level as the BPD group.
Compared with a sample of incarcerated boys in the Netherlands also using CTQ [32], our
groups seems to exhibit more severe scores on neglect and emotional abuse, similar scores on
sexual abuse, and somewhat milder scores on physical abuse. Thus, the level of self-reported
neglect in our AvPD group was substantial.
In contrast to the results based on the CTQ, no between-group differences were detected re-
garding the PBI. According to the PBI scores, low care and high control (i.e., the cold control
pattern) was frequent in both groups. The fact that the PBI did not differentiate between the
disorders in this sample is in agreement with other studies. The dimensions assessed by the
PBI might represent non-specific vulnerability factors for psychopathology across various psy-
chiatric disorders [56]. On the other hand, it might also be due to methodological variations.
CTQ asks for frequencies of different type of maltreatment, whereas PBI asks how they per-
ceive their parents behavior. The patient’s perception of their parent’s behavior might be influ-
enced or distorted by their actual experiences with the parents.
A main strength of the study was the direct comparison of environmental risk factors in
terms of childhood experiences between AvPD and SP. We also took into account tempera-
mental differences between the disorders. Moreover, it is a clinical study with impaired patients
with fully developed disorders. The SP group consisted mainly of patients with GSP, potentially
making it even harder to detect any differences in comparison with AvPD. However, the results
should be interpreted in light of some notable limitations. The small sample size, especially in
the SP group, increased the risk of type II errors. Also, few patients with AvPD without co-
occurring SP in this sample precluded a comparison of pure diagnostic groups though, a fact
that might moderate or camouflage possible differences. Thus, there is a need for replication in
larger samples with pure diagnostic groups. The patient sample comprised chronically poorly
functioning patients [7]. Excluding patients with cluster A and B PDs further limited the repre-
sentativeness of the sample. Thus, the results may not be generalized to a broader psychiatric
population. Despite these limitations, we detected significant and clinically meaningful differ-
ences between the groups. The lack of standardized assessment of simple SP versus GSP (e.g.
MINI plus) is another limitation. However, we compensated by systematically asking patients
to give examples of the extent of their social anxiety, and then we made a general evaluation of

PLOS ONE | DOI:10.1371/journal.pone.0122846 March 27, 2015 10 / 14

 Avoidant PD and Childhood Neglect

all available information. Further, it should be mentioned that age at the time of maltreatment
was not taken into account in this study, i.e., the CTQ asks for the frequency of experiences be-
fore 16 years of age. However, the potential damage of childhood neglect and abuse is likely
more severe at younger ages and during particular sensitive developmental stages [57, 58].
Self-report of childhood trauma is another major limitation. Retrospective reports of early
memories are vulnerable to reconstructive bias resulting from mood and personality, and to
the conscious and unconscious processes of “forgetting”. Although certain specific traumatic
events may stand out as unusual or extreme, abuse and neglect are often part of an ongoing
pattern, and may be stored as scripted or generic memories—reoccurring themes, more than
details of the specific events. The CTQ attempts to elicit these scripted memories by asking re-
spondents how often past events happened, rather than the details of traumatic memories [30].
Moreover, underreporting is probably a larger threat to validity in retrospective reports than
false positive reports [59]. The denial scale of the CTQ aimed to detect such false negative re-
ports. Few patients in this sample scored on this scale, only two had a full score. In the present
sample, patients received different types and length of psychotherapy, which may have influ-
enced their ability to report on childhood trauma. In addition patients with AvPD may have a
general difficulty in appreciating mental states [60, 61]. Unconscious processes, such as dissoci-
ation and attachment organization, might also lead to an inability to recall traumatic memories
[62]. Any differences in attachment organization between AvPD and SP may shed light on
their etiology and should be topics for further research.

Conclusions
To our knowledge this is the first study to compare patients with AvPD and SP regarding child-
hood experiences, parental behavior, and temperament. Our findings suggest that the experi-
ences of physical and emotional neglect in childhood are risk factors for adult AvPD and SP,
most pronounced for AvPD though. The study highlights the potential toll that not being seen,
taken care of, and protected during childhood may have on mental health. The relationship be-
tween AvPD and SP is complex and further research should aim to recruit larger and pure di-
agnostic groups. Childhood neglect may be part of the relational histories woven into the
identity, self-esteem and interpersonal patterns of patients with AvPD, and may contribute to
different degrees of personality dysfunction in patients with AvPD and SP. While in need of
more research, this understanding may be useful for the development and facilitation of psy-
chotherapy more specifically tailored to individuals with AvPD.

Author Contributions
Conceived and designed the experiments: IE JE BH TW. Performed the experiments: IE JE BH
TW. Analyzed the data: IE JE BH TW. Contributed reagents/materials/analysis tools: IE JE BH
TW. Wrote the paper: IE JE BH TW.

References
1. Cox BJ, Pagura J, Stein MB, Sareen J. The relationship between generalized social phobia and avoi-
dant personality disorder in a national mental health survey. Depress Anxiety. 2009; 26(4):354–62. doi:
10.1002/da.20475 PMID: 19031488
2. Hummelen B, Wilberg T, Karterud S, G P. The Relationship between Avoidant Personality Disorder
and Social Phobia. Compr Psychiatry. 2007; 48:348–56. PMID: 17560956
3. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of
12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry.
2005; 62(6):617–27. PMID: 15939839

PLOS ONE | DOI:10.1371/journal.pone.0122846 March 27, 2015 11 / 14

 Avoidant PD and Childhood Neglect

4. Torgersen S, Kringlen E, Cramer V. The prevalence of personality disorders in a community sample.

Arch Gen Psychiatry. 2001; 58(6):590–6. PMID: 11386989
5. Verheul R, Bartak A, Widiger T. Prevalence and construct validity of personality not otherwise specified
(PDNOS). J Pers Disord. 2007; 21(4):359–70. PMID: 17685833
6. Carter SA, Wu KD. Relations among symptoms of social phobia subtypes, avoidant personality disor-
der, panic, and depression. Behav Ther. 2010; 41(1):2–13. doi: 10.1016/j.beth.2008.10.002 PMID:
20171323
7. 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; 26(6):746–63.
8. Lampe L, Sunderland M. Social Phobia and Avoidant Personality Disorder: Similar but Different? J
Pers Disord. 2013; 27:1–16. doi: 10.1521/pedi.2013.27.1.1 PMID: 23342953
9. Marques L, Porter E, Keshaviah A, Pollack MH, Van AM, 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. doi: 10.1016/j.janxdis.2012.05.004 PMID: 22705954
10. Reich J. Avoidant Personality Disorder and its Relationship to Social Phobia. In: Hofmann S.G. &
DiBartolo PM, editor. Social Anxiety; Clinical, Developmental, and Social Perspectives. New York:
Elsevier; 2014. p. 27–41.
11. American Psychiatric Association. Diagnostic and statistical manual of mental disorders ( 3rd ed., rev.)
(DSM-III-R). Washington, DC: Author; 1987.
12. Brook CA, Schmidt LA. Social anxiety disorder: a review of environmental risk factors. Neuropsychiatr
Dis Treat. 2008; 4(1):123–43. PMID: 18728768
13. 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. PMID: 14636393
14. Meyer B, Carver CS. Negative childhood accounts, sensitivity, and pessimism: A study of avoidant per-
sonality disorder features in college students. J Pers Disord. 2000; 14(3):233–48. PMID: 11019747
15. Reichborn-Kjennerud T, Czajkowski N, Torgersen S, Neale MC, Orstavik RE, Tambs K, et al. The rela-
tionship between avoidant personality disorder and social phobia: a population-based twin study. Am J
Psychiatry. 2007; 164(11):1722–8. PMID: 17974938
16. American Psychiatric Association. Diagnostic and statistical manual of mental disorders ( 4th ed.)
(DSM-IV). Washington, DC: Author; 1994.
17. Ralevski E, Sanislow CA, Grilo CM, Skodol AE, Gunderson JG, Shea MT, et al. Avoidant personality
disorder and social phobia: distinct enough to be separate disorders? Acta Psychiatr Scand. 2005;
112(3):208–14. PMID: 16095476
18. Krueger RF. Continuity of axes I and II: toward a unified model of personality, personality disorders,
and clinical disorders. [Review] [106 refs]. J Pers Disord. 2005(3: ):233–61. PMID: 16175735
19. Dimaggio G, Carcione A, Nicolo G, Lysaker PH, d'Angerio S, Conti ML, et al. Differences between axes
depend on where you set the bar: associations among symptoms, interpersonal relationship and alex-
ithymia with number of personality disorder criteria. J Pers Disord. 2013; 27(3):371–82. doi: 10.1521/
pedi_2012_26_043 PMID: 23130814
20. Akiskal HS, Chen SE, Davis GC, Puzantian VR, Kashgarian M, Bolinger JM. Borderline: an adjective in
search of a noun. J Clin Psychiatry. 1985; 46(2):41–8. PMID: 3968045
21. Perugi G, Fornaro M, Akiskal HS. Are atypical depression, borderline personality disorder and bipolar II
disorder overlapping manifestations of a common cyclothymic diathesis? World Psychiatry. 2011;
10(1):45–51. PMID: 21379356
22. Kuo JR, Goldin PR, Werner K, Heimberg RG, Gross JJ. Childhood trauma and current psychological
functioning in adults with social anxiety disorder. J Anxiety Disord. 2011; 25(4):467–73. doi: 10.1016/j.
janxdis.2010.11.011 PMID: 21183310
23. Hernandez A, Arntz A, Gaviria AM, Labad A, Gutierrez-Zotes JA. Relationships between childhood
maltreatment, parenting style, and borderline personality disorder criteria. J Pers Disord. 2012; 26(5):
727–36. PMID: 23013341
24. Johnson JG, Cohen P, Brown J, Smailes EM, Bernstein DP. Childhood Maltreatment Increases Risk
for Personality Disorders During Early Adulthood. Arch Gen Psychiatry. 1999; 56:600–6. PMID:
10401504
25. Yen S, Shea MT, Battle CL, Johnson DM, Zlotnick C, Dolan-Sewell R, et al. Traumatic exposure and
posttraumatic stress disorder in borderline, schizotypal, avoidant, and obsessive-compulsive personali-
ty disorders: findings from the collaborative longitudinal personality disorders study. J Nerv Ment Dis.
2002; 190(8):510–8. PMID: 12193835

PLOS ONE | DOI:10.1371/journal.pone.0122846 March 27, 2015 12 / 14

 Avoidant PD and Childhood Neglect

26. Zhang T, Chow A, Wang L, Dai Y, Xiao Z. Role of childhood traumatic experience in personality disor-
ders in China. Compr Psychiatry. 2012; 53(6):829–36. doi: 10.1016/j.comppsych.2011.10.004 PMID:
22172919
27. Johnson JG, Smailes EM, Cohen P, Brown J, Bernstein DP. Associations between four types of child-
hood neglect and personality disorder symptoms during adolescence and early adulthood: findings of a
community-based longitudinal study. J Pers Disord. 2000; 14(2):171–87. PMID: 10897467
28. Rettew DC, Zanarini MC, Yen S, Grilo CM, Skodol AE, Shea MT, et al. Childhood antecedents of avoi-
dant personality disorder: a retrospective study. J Am Acad Child Adolesc Psychiatry. 2003; 42(9):
1122–30. PMID: 12960713
29. Arbel N, Stravynski A. A retrospective study of separation in the development of adult avoidant person-
ality disorder. Acta Psychiatr Scand. 1991; 83(3):174–8. PMID: 2031461
30. Bernstein DP, Fink L. Childhood Trauma Qusetionnaire; A retrospective Self-Report. San Antonio:
The Psychological Corporation; 1998.
31. Carr CP, Martins CMS, Stingel AM, Lemgruber VB, Juruena MF. The role of early life stress in adult
psychiatric disorders: a systematic review according to childhood trauma subtypes. J Nerv Ment Dis.
2013; 201(12):1007–20. doi: 10.1097/NMD.0000000000000049 PMID: 24284634
32. Nederlof E, Van der Ham JM, Dingemans PM, Oei TI. The relation between dimensions of normal and
pathological personality and childhood maltreatment in incarcerated boys. J Pers Disord. 2010; 24(6):
746–62. doi: 10.1521/pedi.2010.24.6.746 PMID: 21158597
33. Parker G. The Parental Bonding Instrument: psychometric properties reviewed. Psychiatr Dev. 1989;
7(4):317–35. PMID: 2487899
34. Stravynski A, Elie R, Franche RL. Perception of early parenting by patients diagnosed avoidant person-
ality disorder: a test of the overprotection hypothesis. Acta Psychiatr Scand. 1989; 80(5):415–20.
PMID: 2596337
35. Nordahl HM, Stiles TC. Perceptions of parental bonding in patients with various personality disorders,
lifetime depressive disorders, and healthy controls. J Pers Disord. 1997; 11(4):391–402. PMID:
9484698
36. Reti IM, Samuels JF, Eaton WW, Bienvenu OJ III, Costa PT Jr., Nestadt G. Adult antisocial personality
traits are associated with experiences of low parental care and maternal overprotection. Acta Psychiatr
Scand. 2002; 106(2):126–33. PMID: 12121210
37. Torgersen S, Alnaes R. Differential perception of parental bonding in schizotypal and borderline per-
sonality disorder patients. Compr Psychiatry. 1992; 33(1):34–8. PMID: 1555407
38. Bogels S, Stevens J, Majdandzic M. Parenting and social anxiety: fathers' versus mothers' influence on
their children's anxiety in ambiguous social situations. J Child Psychol Psychiatry. 2011; 52(5):599–606.
doi: 10.1111/j.1469-7610.2010.02345.x PMID: 21155774
39. 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. doi: 10.1002/da.20670 PMID:
20143427
40. Rothbart MK, Derryberry D. Temperament in children. In: von Hofsten C, Bäckman L, editors. Psycholo-
gy at the turn of the millennium, vol2: Social, developmental, and clinical perspectives. 2 ed. East Sus-
sex, UK: Psychology Press; 2002. p. 17–35.
41. Rothbart MK, Ahadi SA, Evans DE. Temperament and personality: origins and outcomes. J Pers Soc
Psychol. 2000; 78(1):122–35. PMID: 10653510
42. Prior M, Smart D, Sanson A, Oberklaid F. Does shy-inhibited temperament in childhood lead to anxiety
problems in adolescence? J Am Acad Child Adolesc Psychiatry. 2000; 39(4):461–8. PMID: 10761348
43. Alden LE, Laposa JM, Taylor CT, Ryder AG. Avoidant personality disorder: current status and future di-
rections. [Review] [167 refs]. J Pers Disord. 2002; 16(1):1–29. PMID: 11881158
44. Cox BJ, MacPherson PS, Enns MW. Psychiatric correlates of childhood shyness in a nationally repre-
sentative sample. Behav Res Ther. 2005; 43(8):1019–27. PMID: 15967173
45. Meyer B, Ajchenbrenner M, Bowles DP. Sensory sensitivity, attachment experiences, and rejection re-
sponses among adults with borderline and avoidant features. J Pers Disord. 2005; 19(6):641–58.
PMID: 16553560
46. Arnevik E, Wilberg T, Urnes O, Johansen M, Monsen JT, Karterud S. Psychotherapy for personality dis-
orders: short-term day hospital psychotherapy versus outpatient individual therapy—a randomized con-
trolled study. Eur Psychiatry. 2009; 24(2):71–8. doi: 10.1016/j.eurpsy.2008.09.004 PMID: 19097870
47. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al. The Mini-International
Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychi-
atric interview for DSM-IV and ICD-10. J Clin Psychiatry. 1998; 59 Suppl 20:22–33. PMID: 9881538

PLOS ONE | DOI:10.1371/journal.pone.0122846 March 27, 2015 13 / 14

 Avoidant PD and Childhood Neglect

48. First MB. Structured clinical interview for DSM-IV Axis II personality disorders (vesion 2.0) (SCID II).
New York: New York State Psychiatric Instistute; 1994.
49. Bernstein DP, Fink L, Handelsman L, Foote J, Lovejoy M, Wenzel K, et al. Initial reliability and validity of
a new retrospective measure of child abuse and neglect. Am J Psychiatry. 1994; 151(8):1132–6. PMID:
8037246
50. Bernstein DP, Ahluvalia T, Pogge D, Handelsman L. Validity of the Childhood Trauma Questionnaire in
an adolescent psychiatric population. J Am Acad Child Adolesc Psychiatry. 1997; 36(3):340–8. PMID:
9055514
51. Hardt J, Rutter M. Validity of adult retrospective reports of adverse childhood experiences: review of the
evidence. J Child Psychol Psychiatry. 2004; 45(2):260–73. PMID: 14982240
52. Parker G, Tupling H, Brown L. A parental bonding instrument. Br J Med Psychol. 1979; 52(1):1–10.
53. Posner MI, Rothbart MK. Develpoing mechanisms of self-regulation. Dev Psychopathol. 2000; 12(3):
427–41. PMID: 11014746
54. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5.
Washington, DC: Author; 2013.
55. Skodol AE. Revision of the personality disorder model for DSM-5. Am J Psychiatry. 2011; 168(1):97–8.
doi: 10.1176/appi.ajp.2010.10101466 PMID: 21205815
56. Rey JM, Bird KD, Kopec-Schrader E, Richards IN. Effects of gender, age and diagnosis on perceived
parental care and protection in adolescents. Acta Psychiatr Scand. 1993; 88(6):440–6. PMID: 8310853
57. Perry BD. Childhood Experience and the Expression of Genetic Potential: What Childhood Neglect
Tells Us About Nature and Nuture. Brain and Mind. 2002; 3:79–100.
58. Teicher MH, Samson JA. Childhood maltreatment and psychopathology: A case for ecophenotypic var-
iants as clinically and neurobiologically distinct subtypes. Am J Psychiatry. 2013; 170(10):1114–33.
doi: 10.1176/appi.ajp.2013.12070957 PMID: 23982148
59. Williams LM. Recall of childhood trauma: A prospective study of women's memories of child sexual
abuse. J Consult Clin Psychol. 1994; 62(6):1167–1176. PMID: 7860814
60. Dimaggio G, Attinà G, Popolo R, Salvatore G. Personality disorders with over-regulation of emotions
and poor self-reflectivity—The case of a man with avoidant and not-otherwise specified personality dis-
order and social phobia treated with Metacognitive Interpersonal Therapy. Personal Ment Health. 2012;
6(2):156–62.
61. Semerari A, Colle L, Pellecchia G, Buccione I, Carcione A, Dimaggio G, et al. Metacognitive dysfunc-
tions in personality disorders: correlations with disorder severity and personality styles. J Pers Disord.
2014; 28(6):751–66. doi: 10.1521/pedi_2014_28_137 PMID: 24689762
62. Liotti G. Trauma, dissociation, and disorganized attachment: Three strands of a single braid. Psycho-
therapy. 2004; 41(4):472

PLOS ONE | DOI:10.1371/journal.pone.0122846 March 27, 2015 14 / 14

 CORRECTION

Correction: Avoidant Personality Disorder

versus Social Phobia: The Significance of
Childhood Neglect
Ingeborg Eikenaes, Jens Egeland, Benjamin Hummelen, Theresa Wilberg

The legend for Fig 1, “Attachment style in Avoidant personality disorder (AvPD, n = 70) and
Social phobia (SP, n = 20)” is incorrect. The complete, correct Fig 1 legend can be viewed here.

OPEN ACCESS

Citation: Eikenaes I, Egeland J, Hummelen B,

Wilberg T (2015) Correction: Avoidant Personality
Disorder versus Social Phobia: The Significance of
Childhood Neglect. PLoS ONE 10(5): e0128737.
doi:10.1371/journal.pone.0128737

Published: May 15, 2015

Copyright: © 2015 Eikenaes et al. This is an open

access article distributed under the terms of the
Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are
credited.

PLOS ONE | DOI:10.1371/journal.pone.0128737 May 15, 2015 1/2

Fig 1. Self-reported parental style in the AvPD and SP groups. Distribution of the AvPD and SP groups in the two dimensional, four categorical parental
style model according to the Parental Bonding Instrument (PBI). ORIGO is defined as the cut-off scores, se text. AvPD: Avoidant personality disorder, SP:
Social phobia, M: Mother, F: Father
doi:10.1371/journal.pone.0128737.g001

References
1. Eikenaes I, Egeland J, Hummelen B, Wilberg T (2015) Avoidant Personality Disorder versus Social
Phobia: The Significance of Childhood Neglect. PLoS ONE 10(3): e0122846. doi: 10.1371/journal.
pone.0122846 PMID: 25815817

PLOS ONE | DOI:10.1371/journal.pone.0128737 May 15, 2015 2/2

III
IV
Errataliste
Navn kandidat: Ingeborg Helene Ulltveit-Moe Eikenæs

Avhandlingstittel: Avoidant Personality Disorder and Social Phobia - Studies of Personality Pathology and
Functioning, Childhood Experiences and Attachment.

Forkortelser for type rettelser:

Cor – korrektur

Celtf – endring av sidelayout eller tekstformat

Side Linje Originaltekst Type Korrigert tekst

rettelse

1 23 2.8 Experience in Close Relationship Cor 2.8. Experience in Close Relationship

inventory, ECR. Psychometric inventory, ECR. Psychometric
properties…. properties….s.39

2 1 3.2 Specific aims, hypotheses, and Cor 3.2 Specific aims, hypotheses, and
research questions….s.42 research questions….s.43

2 3 4.1. Settings and design …s.41 Cor 4.1. Settings, design and samples ...s.44

4 24 …over and above the presence of SP, Cor …over and above the presence of SP,
a number of other symptom ... number of other symptom …

9 4 Randomized controlled trials Cor Randomized Controlled Trials

9 10 Specific/ simple SP Cor Specific/ Simple SP

10 12- “moving away from” from other people Cor “moving away from other people”
13

36 4 Adult attachment Cor 2.7.1 Adult Attachment

37 10 Attachment studies in AvPD Cor 2.7.2 Attachment studies in AvPD

38 8 Attachment studies in SP Cor 2.7.3 Attachment studies in SP

48 20 4.2.3 Psychosocial functioning Cor 4.3.3 Work and social functioning

49 1 4.2.4 Quality of life Cor 4.3.4 Quality of life

49 4 4.2.5 Childhood experiences Cor 4.3.5 Childhood experiences

50 15 4.2.7 Temperament Cor 4.3.7 Temperament

50 23 4.2.8 Attachment Cor 4.3.8 Attachment style

54 25 Patients with both disorders also had… Cor Patients with both disorders had…

59 14 Patients in the two AvPD group also Cor Patients in the two AvPD groups also

64 14 ..and paper I that AVPD is… Cor ..and paper I that AvPD is…

78 8 …that the findings in this thesis Cor …that the findings in this thesis will
contribute… contribute…

78 9 …research into treatment for these Cor …research in treatment for these
patients… patients…

0 Avoidant Personality Disorder and Cor Avoidant Personality Disorder and Social
Social Phobia Phobia

Studies of Personality Pathology and Studies of Personality Pathology and

Functioning, Childhood Experiences Functioning, Childhood Experiences and
and Attachment Adult Attachment