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. 2024 Nov 21;19(1):e1644. doi: 10.1002/pmh.1644

The societal costs of avoidant personality disorder

Carl‐Aksel Sveen 1,4,✉, Geir Pedersen 2,5, Theresa Wilberg 3,4, Elfrida Hartveit Kvarstein 4,5
PMCID: PMC11582018  PMID: 39572388

Abstract

The study aims to estimate the societal costs of avoidant personality disorder (AvPD). Cross‐sectional data on AvPD patients during 2017–2020 were retrieved from the quality register of the Norwegian Network for Personality Disorders. Cost estimations were based on a bottom‐up approach, using a structured interview covering the 6‐month period prior to initial assessment. Unit costs were retrieved from public records. The human capital approach was used to calculate productivity losses. Diagnoses were determined according to DSM‐5 by semi‐structured diagnostic interviews (SCID‐5‐PD). Mean societal costs were €19,378 for the total group (N = 410). The subgroup with a single diagnosis (n = 270) incurred €18,818, whereas the subgroup with at least one comorbid PD (n = 140) incurred €20,458. The difference between the two subgroups was not statistically significant. The largest cost component was productivity loss (69%), whereas health service costs constituted 31%. The main contributors to societal costs from the health service cost components were inpatient treatment (18%) and individual outpatient treatment (11%). In conclusion, societal costs for AvPD patients were high, on the same level as borderline PD, schizotypal PD, and schizophrenia, and higher than anxiety disorders, depression, and rheumatoid arthritis. In the future, development of effective AvPD treatment programs enhancing personality functioning and workforce participation is important in order reduce the cost of illness.

INTRODUCTION

Avoidant personality disorder (AvPD) is a severe mental disorder characterized by pervasive patterns of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation (APA, 2013; Weinbrecht et al., 2016). It is a common personality disorder (PD) with a pooled global population prevalence rate of 2.7% (Winsper et al., 2019). In outpatient specialist PD mental health services reported prevalence ranges are 39%–56% (Alnaes & Torgersen, 1988; Hummelen et al., 2007; Sveen, Pedersen, Ulvestad, et al., 2023a). Research on AvPD outlines a pattern of significant psychosocial and occupational impairment, isolation, and experiences of poor life quality (Weinbrecht et al., 2016). With extensive problems of inhibition, introversion, anxiety, and low self‐esteem, relational contexts are challenging, and such problems may complicate AvPD treatment processes (Kvarstein & Karterud, 2013). Although ill health, high costs of health services, poor work functioning, negative stigma, and effective treatments have been documented for borderline PD (BPD) (Keuroghlian et al., 2013; Klein et al., 2022; Storebo et al., 2020), there is far less research on AvPD. The disorder has therefore been characterized as both underrecognized and poorly studied (Lampe & Malhi, 2018; Weinbrecht et al., 2016). More recent studies indicate possible effects of specially focused treatment for patients with AvPD, but evidence is still limited (Simonsen et al., 2022; Weinbrecht et al., 2016; Wibbelink et al., 2023; Wilberg et al., 2023).

It is increasingly established that mental disorders constitute a major economic burden to society, due to treatment costs, lost productivity, and high levels of disability‐adjusted life years (Jo, 2014; Murray et al., 2015; Trautmann et al., 2016). In the pursuit of prevention, treatment, and/or rehabilitation, cost‐of‐illness (COI) studies provide useful information on societal costs, which helps policymakers to formulate and prioritize health‐care policies and interventions and eventually allocate health‐care resources in accordance with budget constraints in order to achieve policy efficiency. Furthermore, COI studies identify relevant cost items to be included in cost‐effectiveness or cost‐utility analyses of new interventions (Jo, 2014). Among mental disorders, COI studies are still limited for PDs. Existing research has documented high health service costs and productivity loss among patients with PD in general (Soeteman et al., 2008; Sveen, Pedersen, Ulvestad, et al., 2023a). A few studies have outlined societal costs for BPD, and a single study has focused on the societal costs of schizotypal PD (Hastrup et al., 2019; Hastrup et al., 2021; Salvador‐Carulla et al., 2014; van Asselt et al., 2007; Wagner, Fydrich, et al., 2014; Wagner, Assmann, et al., 2022). Moreover, economic evaluations include cost of crime related to antisocial/psychopathic traits (Gatner et al., 2023). However, to our knowledge, no studies have, as of yet, specifically estimated the COI for AvPD.

The aim of the present study was to estimate societal costs, including the subcomponents health service costs and productivity loss, among treatment‐seeking patients with AvPD during the 6‐month period prior to assessment at specialized PD treatment units in Norway. As a sizable proportion of AvPD patients have other comorbid PDs, which could have an impact on the results, we also aimed to estimate and compare costs for the two subgroups: patients with AvPD as a single PD and patients with AvPD and other comorbid PDs.

METHOD

Setting and participants

Data for all 410 patients who had been diagnosed with AvPD and had completed a specific interview on health service use and occupational activity (“cost interview”) in the years 2017–2020 were retrieved from the quality register of the Norwegian Network for Personality Disorders (the Network), a nationwide clinical research collaboration (Pedersen et al., 2022). The study included 15 different outpatient treatment units within the Network, which offer specialized treatment for adult patients with a variety of PDs or clinically relevant, subthreshold personality difficulties. In the study sample, 26.8% were male, 73.2% were female, and the mean age was 29.7 (SD = 8.8, range 18–62) years. Furthermore, 270 patients (65.9%) had only an AvPD diagnosis, whereas 140 patients (34.1%) also had at least one comorbid PD diagnosis, whereof 93 had two diagnoses, 35 had three diagnoses, 10 had four diagnoses, and 2 had five diagnoses. The comorbid PD types are displayed in Table 1. See Sveen, Pedersen, Ulvestad, et al. (2023a) for further details on settings, procedures, and treatments.

TABLE 1.

The distribution of comorbid PDs (in addition to avoidant personality disorder).

Frequency Percentage
Schizoid 4 1.0
Schizotypal 2 0.5
Paranoid 44 10.7
Antisocial 4 1.0
Narcissistic 1 0.2
Borderline 88 21.5
Histrionic 0 0.0
Dependent 28 6.8
Obsessive‐compulsive 30 7.3
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Note: N = 140. As some patients are diagnosed with more than one comorbid diagnosis of PD, the percentages will add up to more than 100%.

Diagnostic assessment

Systematic diagnostic evaluation was part of the initial assessment procedure on referral to all treatment units in the network. Patients were diagnosed according to DSM‐5 (APA, 2013), using the Structured Clinical Interview for DSM‐5 Personality Disorders for PD (SCID‐5‐PD) (First et al., 2016). See Sveen, Pedersen, Ulvestad, et al. (2023a) for further elaboration on the diagnostic process.

Costs

In the present COI study, we include both direct and indirect costs. Direct costs cover all actual costs of healthcare utilization, whereas indirect costs cover lost productivity associated with AvPD. Intangible costs, that is, the psychological pain experienced by people with AvPD, are not calculated in the present study as such costs are very difficult to measure and thus are left out in most COI studies (Jo, 2014). Hence, the societal costs in this study are the sum of health service costs and productivity loss. Calculations of health service costs for the total period of 6 months prior to evaluation were estimated using a bottom‐up approach (Jo, 2014), that is, taking the individual patients' reported health service use and multiplying it with the estimated unit cost of each specific cost element. Information on health service utilization, medication, and degree of participation in the labor force during the period 6 months prior to assessment was collected through a specially designed structured cost interview, performed by clinicians as a part of the initial pretreatment assessment.

The productivity loss was measured using the so called human capital approach, that is, calculating the market value of foregone production due to illness (Jo, 2014). The patients reported their workforce absenteeism during the 6‐month period prior to assessment, whereas the unit cost per month of absence from work was set to the average sickness benefit in Norway for that period. Hence, the productivity loss is the months reported as absent from work, times the average sickness benefit.

Table 2 displays all relevant cost items from the cost interview and unit costs of health services and productivity loss. A further elaboration of the cost estimation process, including the estimation of unit costs, is elaborated in a previous study by Sveen, Pedersen, Ulvestad, et al. (2023a) of all DSM‐5 PDs.

TABLE 2.

Unit costs of health services and productivity.

Healthcare consultation/outpatient treatment Cost per consultation
General practitioner 68
Emergency health services
Psychiatric emergency helpline 27
Emergency room 98
Psychiatric outpatient emergency service 273
Ambulant emergency service 299
Outpatient treatment
Individual therapy 273
Group therapy 68
Hospitalization Cost per day
Medical hospital 1702
Psychiatric hospital 1289
Addiction clinic 796
Day‐patient care (medical hospital, psychiatric hospital, addiction clinic) 326
Pharmacological treatment Cost per month of daily treatment
Antidepressants 13
Mood disorder medication 32
Antipsychotics 166
Anti‐anxiety drugs 48
Stimulant medication 85
Analgesics 10
Productivity Loss per month
Productivity 2653
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Note: All unit costs are measured in €, yearend 2018 (exchange rate 9.95 € = 100 NOK). All numbers either are from 2018 or converted to 2018 by the Consumer Price Index of Norway.

Ethics

All participating patients from each treatment unit gave their written consent to use anonymous clinical data for research purposes. Anonymized data were collected and transferred to the quality register. The collection procedures were approved by a local data protection officer at each contributing unit. Data security procedures for the quality register were approved by the data protection officer at the research center of the Network at Oslo University Hospital. Because the data are anonymous, formal approval from the Norwegian State Data Inspectorate and Regional Committee for Medical Research and Ethics is not required (Sveen, Pedersen, Ulvestad, et al., 2023a).

Statistical analysis

Most patients had rather similar and moderate health service costs, but a small proportion of patients had very high costs, mostly due to inpatient treatment (5% within the study sample was admitted to a psychiatric hospital). As many as 79.5% of the patients had been out of the workforce during all 6 months, incurring a large productivity loss whereas only 9.3% had no productivity loss. The distribution of societal costs, the sum of health service costs and productivity loss, reflects the distributions of the subcomponents. As all cost data in the present study were non‐normally distributed, not only means but also medians and ranges are presented in Section 3.

Comparison of means (independent samples t‐tests) assumes independent samples and normally distributed populations from which the samples are taken, or that the sample sizes should be large enough to be robust to non‐normality (e.g. >30, according to the central limit theorem) (Ledolter et al., 2020). Thus, parametric procedures can be used even when the data are not normally distributed (Ghasemi & Zahediasl, 2012). As a control of the robustness of the results from the t‐tests, non‐parametric bootstrapping (2000 resamplings) was also performed.

Data entry, calculation of costs, and comparison of means between subgroups were performed using IBM SPSS Statistics version 29.

RESULTS

Table 3 presents mean costs by cost category for the 6‐month period prior to assessment, for the total sample diagnosed with AvPD during 2017–2020 (N = 410), and the mean costs for the two different subgroups: patients diagnosed with only AvPD (n = 270) and patients diagnosed with AvPD and at least one comorbid PD (n = 140).

TABLE 3.

Health service costs, productivity loss, and total societal costs.

All patients with AvPD (N = 410) Patients with only AvPD (n = 270) Patients with AvPD and at least one comorbid PD (n = 140)
Mean costs Percentage of societal costs Mean costs Percentage of societal costs Mean costs Percentage of societal costs
General practitioner 235 1.21 201 1.07 301 1.47
Emergency health services 89 0.46 87 0.46 95 0.47
Outpatient treatment 2088 10.78 1904 10.12 2440 11.93
Hospitalization 3498 18.05 3220 17.11 4035 19.72
Pharmacological treatment 132 0.68 120 0.64 152 0.74
Sum health service costs 6042 31.18 5532 29.40 7023 34.33
Productivity loss 13,336 68.82 13,286 70.60 13,435 65.67
Societal costs 19,378 100 18,818 100 20,458 100.00
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Note: All costs measured in the 6‐month period prior to assessment. Unit costs are measured in €, yearend 2018. Standard deviations are not included in the table as all distributions are non‐normal. Both the subcategories and the sum of health service costs are presented in the table. Societal cost is the sum of productivity loss and health service costs.

Abbreviation: AvPD, avoidant personality disorder.

Mean productivity loss was the largest cost component (68.8% of societal costs)—estimated to €13,336 per patient for the total sample for the 6‐month period (range €0–€15,928, median €15,928). The total health service cost estimate per patient for the total sample was €6,042 for the 6‐month period (range €0–€163,046, median €1,939), constituting 31.2% of societal costs. Inpatient health care (18.1%) and outpatient therapy (10.8%) were the main health service contributors to total societal costs. All other health service cost components had a minimal contribution to the societal costs (range 0.5%–1.2%). The mean societal cost was €19,378 for the 6‐month period (range €0–€178,974, median €16,890).

The subgroup of patients with only an AvPD diagnosis had a mean productivity loss estimate of €13,286 (range €0–€15,928, median €15,928) (see Table 3). The mean health service costs estimate was €5,532 (range €0–€127,294, median €1,440). Thus, the estimate of mean societal costs for the patients with only AvPD was €18,818 (range €0–€143,222, median €16,462).

The other subgroup of patients with AvPD, who had at least one comorbid PD, had an estimated level of mean productivity loss of €13,435 (range €0–€15,928, median €15,928) (see Table 3). The mean health service costs estimate was €7,023 (range €0–€163,046, median €3,283), resulting in mean societal costs of €20,458 (range €0–€178,974, median €18,206).

When comparing means between the two subgroups by using independent samples t‐tests, no statistically significant differences were found regarding societal costs, see Table 4. As a control, means were also compared using non‐parametric bootstrapping, resulting in a one‐sided p value = 0.153, thus strengthening the conclusion of the t‐test.

TABLE 4.

Comparison of means between the patients with only AvPD and the patients with AvPD and at least one comorbid PD.

N Mean SD One‐sided p value
Societal costs Only AvPD 270 18,818 16,540 0.178 a
AvPD+ 140 20,458 17,924
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Note: AvPD+ = AvPD and at least one comorbid PD.

Abbreviations: AvPD, avoidant personality disorder; SD, standard deviation.

a

According to the outcome of Levene's test for equality of variances, equal variance is assumed for all variables.

DISCUSSION

To our knowledge, this is the first study to document explicitly the societal costs of AvPD. The mean societal costs incurred by the total group of patients with AvPD (n = 410) amounted to €19,378 per person during the 6‐month period before assessment and was just marginally lower (4.6%) than the societal costs found among a group of 911 patients with a broader range of PDs from the Network (€20,260) (Sveen, Pedersen, Ulvestad, et al., 2023a). The subgroup of patients with a single AvPD diagnosis had somewhat lower mean societal costs (€18,818) than the total group of AvPD patients, whereas the subgroup with at least one comorbid PD had the highest mean societal costs (€20,458), indicating that the presence of comorbid PDs could imply higher levels of societal costs. However, no statistically significant differences were found when mean societal costs between the two subgroups were compared (p value = 0.178), that is, the societal costs of AvPD do not differ significantly by the presence of comorbid PDs or not. This is also in line with findings from another study from the Network investigating different severity indicators' association with societal costs in a mixed PD sample, including the number of PDs as a predictor variable, as increasing number of PDs did not significantly impact the mean level of societal costs (Sveen, Pedersen, Hummelen, & Kvarstein, 2023).

The societal costs of AvPD found in the present study were approximately on the same level as the societal costs of both BPD and schizotypal PD as identified in recent Danish register studies, when the difference in measurement periods was accounted for (Hastrup et al., 2019; Hastrup et al., 2021), emphasizing the high and comparable societal costs of AvPD to other PDs. Furthermore, Wagner et al. conducted two different studies of the societal costs of treatment‐seeking patients diagnosed with BPD in Germany and found societal costs somewhat lower than our estimate for AvPD, even when the €‐inflation up until 2018 and the difference in measurement period is considered (Wagner, Fydrich, et al., 2014; Wagner, Assmann, et al., 2022). In addition, the mean societal costs of AvPD are comparable with the societal costs of schizophrenia and significantly higher than the societal costs of both depression and anxiety disorders (Konnopka et al., 2009; Lin et al., 2023; Luppa et al., 2007; Sveen, Pedersen, Ulvestad, et al., 2023a). Thus, the societal costs of AvPD were high and comparable with other PDs and other severe mental disorders. Also, when compared with a chronic, possibly debilitating physical illnesses such as rheumatoid arthritis, AvPD is generally associated with a higher level of societal costs. For instance, in their systematic review, Hsieh et al. (2020) found that the majority of annual societal cost estimates were in the range 10,000–30,000 USD per person (2017), clearly lower than the annualized societal cost estimate of AvPD from the present study (using the €/$ exchange rate yearend 2017 of 1.19%, and the €‐inflation rate from 2017 to 2018 of 1.89%).

Productivity loss is clearly the largest cost component, constituting more than two thirds of the societal costs, as nearly 80% of the total AvPD patient group were not participating in the workforce during the 6‐month measurement period. This is somewhat higher than found in two studies of a broader range of PDs from the network, that is, 75% and 72.6% respectively, with a stronger negative impact on productivity loss associated with AvPD relative to other PDs (Sveen, Pedersen, Ulvestad, et al., 2023a; Sveen, Pedersen, Ulvestad, et al., 2023b). In line with former research pointing to poor social functioning among these patients (Kvarstein et al., 2021; Weinbrecht et al., 2016), our results further underscores that AvPD may represent particular challenges when it comes to participation in the labor marked. The patients' social avoidance and fear of negative evaluation may make it difficult to complete education, apply for jobs, as well as interacting with colleagues.

Mean health service costs for the total AvPD group constituted less than one third of the societal costs. Hospitalization and outpatient treatment were the most prominent health service cost items. The estimates were particularly low for the patients with AvPD as a single PD diagnosis compared with the patients with at least one additional PD. It may not be surprising that patients with a single diagnosis of AvPD were hospitalized to a lesser degree than patients with other comorbid PDs, The most frequent comorbid PD was BPD, known to be associated with considerable affect instability, self‐harm, and suicidal crises (Choi‐Kain et al., 2022). It is noteworthy that this group also received less outpatient treatment. A single PD diagnoses could reflect a more moderate PD condition (Zimmerman et al., 2018). However, a recent Norwegian study found no significant impact of increasing numbers of PDs on health service costs (Sveen, Pedersen, Hummelen, & Kvarstein, 2023). Furthermore, poor social functioning was evident among both single and comorbid AvPD patients in this study. Nonetheless, single AvPD may reflect a somewhat larger concentration of introvert pathology, be harder to reach, and display less help‐seeking behaviors.

The mean health service costs for the total AvPD group were 17.6% lower than the health service costs found in the abovementioned study of a broad range of PDs (€6,042 vs. €7,110) (Sveen, Pedersen, Ulvestad, et al., 2023a). However, in a recent study investigating the relative impacts of specific PDs, non‐significant impact of AvPD on health service costs were indicated (Sveen, Pedersen, Ulvestad, et al., 2023b). The apparent difference in health service cost estimates in the present study must therefore be interpreted with caution as the variance in health service costs generally is large in these samples of treatment‐seeking patients.

In the present article, with data collected for the years 2017–2020 in Norway, the current categorical diagnosis of AvPD from DSM‐5 was used, requiring that the patients met at least four out of seven diagnostic criteria. However, both DSM and ICD are shifting towards a more dimensional approach to personality pathology. As AvPD is associated with significant psychosocial impairment and societal costs (Weinbrecht et al., 2016), it is important that future dimensional classifications will be able to capture this kind of personality pathology.

The alternative model of PDs (AMPD) in DSM‐5 is a hybrid dimensional/categorical model representing PDs as core impairments in self and interpersonal functioning combined with specific pathological personality traits (APA, 2013). Impairments in self and interpersonal functioning include the domains identity, self‐direction, empathy, and intimacy evaluated on a global 5‐point rating scale, the Level of Personality Functioning Scale (LPFS). The 25 specific pathological traits are organized within five broad trait domains, that is, Negative affectivity, Detachment, Disinhibition, Antagonism, and Psychoticism. The AMPD has retained AvPD as one of six specific PD categories with proposed typical specific impairments of personality functioning (“AvPD specific impairment”) and specific pathological traits like anxiousness, withdrawal, anhedonia, and intimacy avoidance (APA, 2013).

Quite similar to AMPD, the ICD‐11, which already is implemented in several countries but not yet in Norway, evaluate PD dimensionally in terms of severity of personality functioning impairment, and with partly overlapping domains of pathological personality traits. However, in contrast to AMPD, ICD‐11 has abolished the established PD categories except for a borderline specifier. Moreover, specification of individual pathological traits is not mandatory in ICD‐11 (Reed, 2018; Simon et al., 2023) with the risk of less nuanced descriptions of the pathology.

There is hitherto limited research focusing on to which degree the forthcoming dimensional models capture the longstanding categorical conceptualization of AvPD. A recent review of the ICD‐11 trait domains found that AvPD was consistently correlated with the broad trait domains negative affectivity and detachment, which is conceptually meaningful (Simon et al., 2023). However, the review by Hummelen et al. (2022) focusing on AMPD and LPFS raised some concern that the LPFS may not be sufficiently able to capture AvPD and that measures of specific AvPD impairment in personality functioning may be needed (Hummelen et al., 2022). More knowledge of the relevance and specificity of the specific pathological traits associated with AvPD is also called for (Watters et al., 2019). Thus, more research on the cross‐walking between the traditional AvPD category and a dimensional model is needed. Of note, as the classification systems are changing to more dimensional models, the concept of AvPD may be changing as well, which could render different estimates of the societal costs of AvPD. Hence, future research on the societal costs of AvPD should include a dimensional conception of AvPD.

Strengths and limitations

The present study includes a high number of patients with AvPD, with data collected nationwide in different settings, hence enhancing the external validity of the results. Yet, the study sample consists of treatment‐seeking patients with AvPD and the results may thus not be representative for the overall AvPD patient population.

There is a high level of accuracy and validity of the unit costs used in the calculation of health service costs as most unit costs included not only variable costs/fees but also the proportion of fixed costs attributable to each unit. This was possible due to the comprehensiveness and high quality of public health reports and official unit cost registers in Norway (Sveen, Pedersen, Ulvestad, et al., 2023a).

Nineteen percent of the patients in the quality register had not completed the cost interview by the time of data extraction to the present COI, which could have led to biased cost estimates. However, possible bias would probably be negligible as we found no significant differences with respect to gender or age between those who had completed the cost interview, and thus were included in this study, and those who were not.

Other cost items could have been included in the cost interview, such as costs to society due to criminality and home care costs. However, among patients with PDs, it is foremost patients with antisocial PD who are associated with costs of crime to society (Fazel & Danesh, 2002). As we are focusing on AvPD in this study, the effect on costs by omission of such cost items would probably be negligible.

Diagnoses were set using clinical interviews, and diagnostic reliability was not directly estimated in this study. However, the interviewers had received systematic training in diagnostic interviews and principles, and all diagnoses were set or evaluated by a specialist in psychiatry or clinical psychology (Sveen, Pedersen, Ulvestad, et al., 2023a). Furthermore, in a former study using the Structured Clinical Interview for DSM‐IV (SCID‐II—the previous version of SCID‐5‐PD) within the same network, reliability was investigated and acceptable diagnostic reliability was indicated (Gullestad et al., 2012).

The use of health services data and workforce participation are collected retrospectively and may be susceptive to recollection bias. The relatively short measurement period of 6 months was set to reduce this, but the limited range may have reduced the variation in the sample at the same time (Sveen, Pedersen, Ulvestad, et al., 2023a).

CONCLUSION

This study demonstrates that treatment‐seeking patients with AvPD incur a high level of societal costs, comparable with other PDs such as BPD and schizotypal PD, as well as schizophrenia, a disorder known to represent a substantial economic burden to society. Furthermore, AvPD is associated with higher societal costs than anxiety disorders and depression and even a chronic physical illness such as rheumatoid arthritis. Indirect costs in the form of productivity loss is the dominant factor of societal costs for patients with AvPD, as for other PDs. Patients with AvPD as a single PD diagnosis displayed somewhat lower mean societal costs than AvPD patients with comorbid PDs, but the difference was not statistically significant. In the future, development of effective treatment programs for AvPD patients should be equally important as for other PDs, such as BPD, and should focus on enhancing personality functioning and workforce participation, addressing the high level of societal costs associated with the disorder.

CONFLICT OF INTEREST STATEMENT

All authors declare that they have no conflicts of interest.

ETHICS STATEMENT

All participating patients from each treatment unit gave their written consent to use anonymous clinical data for research purposes. Anonymized data were collected and transferred to the quality register. The collection procedures were approved by a local data protection officer at each contributing unit. Data security procedures for the quality register were approved by the data protection officer at the research center of the Network at Oslo University Hospital. Because the data are anonymous, formal approval from the Norwegian State Data Inspectorate and Regional Committee for Medical Research and Ethics is not required.

ACKNOWLEDGMENTS

We wish to thank the patients, staff, and research coordinators from the Norwegian Network for Personality Disorders for their contribution to this study. The collaboration includes the following units: Unit for Group Therapy, Øvre Romerike District Psychiatric Center, Akershus University Hospital, Jessheim; Group Therapy Unit, Nedre Romerike District Psychiatric Center, Akershus University Hospital, Lillestrøm; Group Therapy Unit, Follo District Psychiatric Center, Akershus University Hospital, Ski; Group Therapy Unit, Groruddalen District Psychiatric Center, Akershus University Hospital, Oslo; Group Therapy Unit, District Psychiatric Center, Ålesund Hospital, Ålesund; Clinic for Personality disorders, Outpatient Clinic for Specialized Treatment of Personality Disorders, Section for Personality psychiatry and specialized treatments, Oslo University Hospital, Oslo; Group Therapy Unit, Lovisenberg District Psychiatric Center, Lovisenberg Hospital, Oslo; Group Therapy Team, Vinderen Psychiatric Center, Diakonhjemmet Hospital, Oslo; Unit of Personality psychiatry, Vestfold District Psychiatric Center, Sandefjord; Unit for Intensive Group Therapy, Aust‐Agder District Psychiatric Center, Sørlandet Hospital, Arendal; Unit for Group Therapy, District Psychiatric Center, Strømme, Sørlandet Hospital, Kristiansand; Group Therapy Unit, Stavanger District Psychiatric Center, Stavanger University Hospital, Stavanger; Section for group treatment, Kronstad District Psychiatric Center, Haukeland University Hospital, Bergen; MBT Team, Department of Substance Abuse Medicine, Haukeland University Hospital, Bergen; MBT‐Team, Outpatient Clinic, Rogaland A‐senter, Stavanger.

Sveen, C.‐A. , Pedersen, G. , Wilberg, T. , & Kvarstein, E. H. (2025). The societal costs of avoidant personality disorder. Personality and Mental Health, 19(1), e1644. 10.1002/pmh.1644

Funding information: This research received no specific grant from any funding agency, commercial, or not‐for‐profit sectors.

DATA AVAILABILITY STATEMENT

Due to restrictions imposed by the Regional Medical Ethics Committee regarding patient confidentiality, data are available upon request. Requests for data may be sent to the hospital's Privacy and Data Protection Officer (personvern@ous-hf.no).

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Data Availability Statement

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