DSM-III and The Emergence of Avoidant Personality Disorder

Disorders of introversion were split into discrete categories in the DSM-III.

Posted Oct 08, 2019

     In the context of multiple problems with the DSM-I and DSM-II, including lack of clear definitions and poor inter-rater reliability, the DSM-III instituted observable, descriptive, and atheoretical diagnostic criteria to facilitate reliable diagnosis (DSM-III, APA, 1980, p. 8).  DSM-III (APA, 1980, p. 8) highlighted their purpose of specifying diagnostic borders and clearly defining content of diagnostic categories.

     For each mental disorder listed, the DSM-III (APA, 1980) provided a definition of its (a) essential features (i.e., characteristics that are necessary for a given diagnosis), (b) associated features, (i.e., characteristics that commonly co-occur with a given diagnosis but are not necessary conditions of the diagnosis), (c) diagnostic criteria (i.e., a list of observable characteristics), as well as, (d) the available relevant psychosocial, demographic, diagnostic, prognostic, and epidemiological information pertaining to a given diagnosis, such as the differential diagnosis (i.e., identification of syndromes that should be differentiated from a given diagnosis (DSM-III, APA, 1980, p. 31).  In addition, DSM-III (APA, 1980) initiated a multiaxial diagnostic system in which PDs and certain developmental disorders, placed on Axis II, were separated from all other mental disorders, placed on Axis I (p. 23, DSM-III, APA, 1980).

     Several authors have reported that DSM-III (APA, 1980) represented a shift within psychiatry back to the descriptive psychiatry of Kraepelin and away from the psychodynamic model (Bornstein, 2006; Havens, 1981; Wilson, 1993). Wilson (1993) emphasized that DSM-III definitions of psychopathology, in general, lacked clinically relevant material with a focus on the loss of psychodynamic concepts such developmental experiences, internal conflicts, and unconscious dynamics in favor of the proliferation of overly simple, discrete categories. In DSM-III (APA, 1980), there were marked changes to the DSM-I and DSM-II constructs described above.

     Bornstein (2006) pointed out that DSM-III essentially removed all of schizoid PD’s psychodynamic characteristics (see Ahktar, 1987, for a comprehensive review). In addition, due to widespread criticism of simple schizophrenia for its over-generality and poor reliability, the category of simple schizophrenia was removed from the nomenclature starting with DSM –III into the present (APA, 1980; see Black & Boffeli, 1989 for a review).

     Multiple literature reviews report that the pre-DSM-III schizoid PD construct was subcategorized into three different personality disorders—redefined schizoid PD, avoidant PD, and schizotypal PD—in DSM-III (e.g., Bernstein & Travaglini, 1999; Livesley, West & Tanney 1985; Mittal, Kalus, Bernstein, & Siever, 2007; also, see e.g., Alden, Laposa, Taylor, & Ryder, 2002; Skodol & Gunderson, 2010). According to Kalus et al. (1995, p. 58) this subdivision attempted to meet the DSM-III’s (APA, 1980) goals of increased definitional specificity, reliability, and accuracy of diagnosis. DSM-III (APA, 1980) defined the essential features of the new syndrome, avoidant PDs follows:

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...hypersensitivity to potential rejection, humiliation, or shame; an unwillingness to enter into relationships unless given unusually strong guarantees of uncritical acceptance; social withdrawal in spit of a desire for affection and acceptance; and low self-esteem. Individuals with this disorder are exquisitely sensitive. . . .Unlike individuals with Schizoid Personality Disorder, who are socially isolated but have no desire for social relations, those with Avoidant Personality Disorder yearn for affection and acceptance. They are distressed by their lack of ability to relate. . . (DSM-III, APA, 1980, pp. 323 – 324)

In addition, symptoms of anxiety and depression were associated features of avoidant PD, consistent with the DSM-III’s (APA, 1980) conceptualization of social isolation in avoidant PD as ego-dystonic, linked with subjective distress and loneliness, in contrast to its conception of ego-syntonic social isolation in schizoid PD (see Skodol & Gunderson, 2010, for a review). Livesley et al. (1985) was the first to draw critical attention to the DSM-III’s postulated underlying difference between schizoid PD and avoidant PD, namely the drive—or lack thereof—to make meaningful connections with people. In line with the DSM-III’s conception of the new avoidant PD construct, DSM-III (APA, 1980) made considerable changes to the definition of schizoid PD and defined its essential features as follows:

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...a defect in the capacity to form social relationships, evidenced by the absence of warm, tender feelings for others and indifference to praise, criticism, and the feelings of others . . . . Individuals with this disorder show little or no desire for social involvement, usually prefer to be ‘loners,’ and have few, if any close friends. They appear reserved, withdrawn, and seclusive and usually pursue solitary interests or hobbies. . .are usually humorless or dull and without affect in situations in which an emotional response would be appropriate. . . . usually appear ‘cold’ and aloof. (p. 310)

Black and Boffeli (1989) reported that the APA Task Force for DSM – III attempted to redefine the concept of the Schizoid Personality in a way closer to its original meaning. However, this view has been extensively challenged by comprehensive historical studies of the concept of the schizoid personality which show that the term originally referred to a complex cluster of traits (as described earlier) that seem more consistent with its DSM-I and DSM-II definitions than its DSM – III version (e.g., Ahktar 1987; Livesley 1985).

     The lack of expressed aggression characteristic of the schizoid personality in DSM-I and DSM-II was removed as a core feature but retained as an associated feature of the disorder in DSM-III (APA, 1980). The DSM-III (APA, 1980) also noted that it remained unclear whether schizoid PD signaled a risk for developing schizophrenia (i.e., a separate syndrome) or was in itself a form of prodromal schizophrenia (i.e., presence of schizophrenia prior to its full-blown, expression). In addition, the concept of ambivalence was similarly removed as an essential feature but retained as an associated feature. Other associated features of DSM-III (APA, 1980) schizoid PD included daydreaming, self-absorption, detachment (e.g., ‘in a fog’), and poor social skills. DSM-III (APA, 1980).

     The emphasis on the internal sensitivity of schizoid individuals—in contrast to their detached, flat appearance—was omitted (see Livesley et al., 1985, for a review). Instead, it was allocated as a core feature of DSM-III avoidant PD (e.g., Ahktar, 1987; Livesley et al., 1985; for reviews, see Bernstein & Travaglini, 1999; Kalus et al., 1995; Miller et al., 2001; Mittal et al., 2007). Ahktar (1987) pointed out that this oversimplified the schizoid PD construct which was originally viewed from a psychodynamic lens as marked by the contrast between internal sensitivity/emotional-conflict and outward detachment/flat-affect.

       According to the DSM-III (APA, 1980), both individuals with schizoid and avoidant PDs could be described as reclusive; however, in addition to their lack of interest in relationships, individuals with schizoid PD were thought to be indifferent to the opinions—positive or negative—of other people. In contrast, individuals with avoidant PD theoretically wanted relationships and were plagued by chronic low self-esteem as well as hypersensitivity to the opinions of others (DSM-III, APA, 1980; see Livesley et al., 1985, for a review). Consistent with their historical unity in the DSM series, DSM-III (APA, 1980) indicated the similarity between schizoid and avoidant PD by listing avoidant PD as a differential diagnosis of schizoid PD (and vice versa), suggesting their common external appearance and overlapping clinical presentation.

      Specifically, DSM-III (APA, 1980) described schizoid PD and avoidant PD as distinguishable by virtue of there being distinct causes or reasons for the social isolation and interpersonal impairment common to both syndromes (Miller et al., 2001). This distinguishing feature of DSM-III schizoid PD has been conceptualized as indicating a fundamental impairment or deficit in the motivation or capacity for emotional involvement with others (DSM-III, APA, 1980; Millon, 1981; 1985; for reviews, see e.g., Livesley et al., 1985; Miller et al., 2001; Mittal et al., 2007). Furthermore, it has been retained in all subsequent versions of the DSM as the core differentiating characteristic of schizoid and avoidant personality disorders as well as the source of much controversy to be described further in the relevant sections below (Livesley et al., 1985 v. Millon, 1986; see e.g., Bernstein & Travaglini, 1999, for a review). 

     Consistent with the DSM-III’s (APA, 1980) increased emphasis on categorization (Wilson, 1993), Axis-II PDs were classified into one of three separate clusters, with schizoid PD classified with schizotypal and paranoid PDs in connection to their shared “odd or eccentric” appearance as well as their descriptive overlap and theoretical-genetic links with schizophrenia (Bernstein & Travaglini, 1999; Livesley et al., 1985; Miller et al., 2002; Mittal et al., 2007).

     Accordingly, this cluster, now known as Cluster A, has been conceptualized as comprised of “schizophrenia-spectrum” PDs, a construct dating back to Kraepelin (cf. Kraepelin, 1902/1912) and his contemporaries (e.g., Hoch, 1910; Bleuler, 1924/1951; Kretschmer, 1925; see Miller et al., 2001; Mittal et al., 2007, for reviews). In contrast, avoidant PD was classified with dependent, compulsive, anxious, and passive-aggressive PDs for their shared “fearful or anxious” appearance (DSM-III, APA, 1980; for reviews, see e.g., Kalus, Bernstein, & Siever, 1995; Miller et al., 2001).