The Dual Diagnosis Pages: "From Our Desk"
Article posted 25 March, 2000


Dual Diagnosis and the Avoidant Personality Disorder

Table of Contents

  • The Avoidant Personality Disorder
  • Treating the The Avoidant Personality Disorder
  • Dual Diagnosis Treatment: Treating the Addicted Avoidant Personality Disorder
  • For references, see the Bibliography page

    Cluster C:
    The Avoidant Personality Disorder (AvPD)

    Essential Feature

    The essential feature of the avoidant personality disorder is a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation (DSM-IV, 1994, p. 662).

    The ICD-10 (1994, p. 232) has a personality disorder called the anxious (avoidant) personality disorder characterized by feelings of tension, apprehension, insecurity and inferiority. These individuals wish to be liked and accepted but experience hypersensitivity to rejection and criticism. Personal attachments are restricted. People with the anxious personality disorder have a tendency to avoid activities by a habitual exaggeration of the potential dangers or risks involved. They believe that they are socially inept, personally unappealing and inferior.

    Millon & Davis (1996, pp. 253-256) call AvPD the withdrawn pattern. These are individuals who are oversensitive to social stimuli and are hyperreactive to the moods and feelings of others. Individuals with AvPD are chronically overreactive and hyperalert, with affective disharmony, cognitive interference, and interpersonal distrust. They are disposed toward the more severe schizophrenic disorders. Historically, this pattern has been described as being preoccupied with security and strained in associating with people.

    Everly (Retzlaff, ed., 1995, pp. 25-38) states that the most severe pathology found in AvPD is in the area of self-image. In AvPD there is the failure of the core personality to adapt in a competent manner to interpersonal adversity -- presumably both past and present. Stone (1993, p. 355) also sees the key traits of AvPD as social reticence and avoidance of interpersonal activities. These individuals are easily hurt by criticism and fear showing their anxiety in public. They would like to be close to others and to live up to their potential, but are afraid of being hurt, rejected, and unsuccessful (Beck, 1990, p. 43).

    There is overlap between AvPD and social phobia, generalized type (DSM-IV, 1994, pp. 663-664). The essential feature of social phobia (social anxiety disorder) is a marked and persistent fear of social or performance situations that may provoke embarrassment. Most often, the social or performance situation is avoided though it may be endured with dread. The avoidance, fear or anxious anticipation must interfere significantly with daily routine, occupational functioning, or social life or cause significant personal distress (DSM-IV, 1994, p. 411). Sutherland & Frances (Gabbard & Atkinson, eds., 1996, p. 991) suggest that AvPD and social phobia are constructs that differ only in the severity of dysfunction. Frances, et.al. (1995, p. 376) propose the possibility that they are two different constructs for the same condition. Benjamin (1993, p. 294) notes that the interpersonal patterns for generalized social phobia are very similar to AvPD; both groups avoid social contact and restrain themselves because of fear of humiliation or rejection. She proposes that social phobia is diagnosed if symptoms of pervasive anxiety or panic are present. Millon and Martinez (Livesley, ed., 1995, p. 222) believe that the avoidant personality is essentially a problem of relating to people while social phobia is largely a problem of performing in situations. Stone (1993, pp. 355-356) suggests that social phobia, agoraphobia, and OCD often have an underlying AvPD.

    It is common for persons with AvPD to have comorbidity with other personality disorders. AvPD is most often diagnosed with DPD, BPD, PPD, SPD, or StPD (DSM-IV, 1994, p. 663). Frances, et.al (1995, p. 376) note the considerable overlap between AvPD and DPD. These two personality disorders share interpersonal insecurity, low self-esteem, and a strong desire for interpersonal relationships. Benjamin (1993, p.301) describes the desperate attempts to avoid being alone that may be seen in DPD as an exclusionary indicator for AvPD.

    AvPD is found equally in males and females (DSM-IV, 1994, p. 663).

    Self-Image

    Individuals with AvPD are preoccupied by the unpleasant and perplexing personal definition they hold of themselves as defective, unable to fit in with others, being unlikable, and being inadequate. This self-image usually results from childhood rejection by significant others such as parents, siblings, or peers. These individuals then believe that others throughout their lives will react to them in a similar fashion. They are often unable to recognize their own admirable qualities that make them both likable and desirable (Will, Retzlaff, ed., 1995, p. 97). Rather, they see themselves as socially inept and inferior. They believe that they are personally unappealing and interpersonally inadequate. They describe themselves as ill at ease, anxious, and sad. They are lonely; they feel unwanted and isolated. Individuals with AvPD are introspective and self-conscious. They usually refer to themselves with contempt (Millon & Davis, 1996, p. 263).

    For individuals with AvPD, their deflated self-image references their entire being. Nothing about them escapes their own self-derision (Millon & Davis, 1996, p. 264). Doubts about their social competence and personal appeal become especially severe in the presence of strangers (DSM-IV, 1994, p. 662).

    View of Others

    Individuals with AvPD view the world as unfriendly, cold, and humiliating (Millon & Davis, 1996, p, 265). People are seen as potentially critical, uninterested, and demeaning (Beck, 1990, pp. 43-44); they will probably cause shame and embarrassment for individuals with AvPD. As a result, people with AvPD experience social pananxiety and are awkward and uncomfortable with people (Millon & Davis, 1996, p. 261). However, they are caught in an intense approach-avoidance conflict; they believe that close relationships would be rewarding but are so anxious around people that their only solace or comfort comes in avoiding most interpersonal contact (Donat, Retzlaff, ed., 1995, p. 49).

    Individuals with AvPD tend to respond to low-level criticism with intense hurt. To make matters worse, they become so socially apprehensive that neutral events may well be interpreted as evidence of disdain or ridicule by others (Donat, Retzlaff, ed., 1995, p. 49). They come to expect that attention from others will be degrading or rejecting. They assume that no matter what they say or do, others will find fault with them (DSM-IV, 1994, p. 662).

    Even memories for individuals with AvPD are comprised of intense, conflict-ridden, problematic early relationships. They must avoid the wounds inside of them at the same time they are avoiding the external distress of contact with others. The external environment brings no peace and comfort and their painful thoughts do not allow them to find solace within themselves (Millon & Davis, 1996, pp. 263-264).

    Relationships

    Individuals with AvPD are "lonely loners." They would like to be involved in relationships but cannot tolerate the feelings they get around other people. They feel unacceptable, incapable of being loved, and unable to change. Because they retreat from others in anticipation of rejection, they lead socially impoverished lives. They have immature and unrealistic expectations of relationships; they believe that they can have no imperfections if they are to be accepted and loved. Interpersonally, they are ill at ease, awkward and tense. They experience unremitting self-consciousness, self-contempt and anger toward others (Oldham, 1990, pp. 188-193).

    Individuals with AvPD will develop intimacy with people who are experienced as safe. Nevertheless, they will often engage in triangular marital or quasi-marital relationships which provide intimacy while maintaining interpersonal distance. These individuals like to foster secret liaisons as a "fall-back" position in case the key relationship does not work out (Benjamin, 1983, pp. 307-308). As sexual partners and parents, people with AvPD appear self-involved and uncaring (Kantor, 1992, p. 109) as they preserve distance from others through defensive restraint and withdrawal. Even so, these individuals long for affection and fantasize about idealized relationships (DSM-IV, 1994, p. 663).

    Issues With Authority

    Individuals with AvPD are unlikely to provoke or resist authority. At least at a behavioral level, they are inclined to be compliant and cooperative. However, whether the authority figures are service providers or law enforcement officers, people with AvPD are not forthcoming and resist self-disclosure. Exposure means, for these individuals, ridicule, shame, and censure. They will not willingly give away the information that they believe will result in such painful experiences.

    AvPD Behavior

    Individuals with AvPD behave in a fretful, restive manner. They overreact to innocuous experiences but maintain control over their physical behaviors and expression of emotions. Their speech is hesitant and constrained. They appear to have fragmented thought sequences and their conversation is laced with confused digressions. They are timid and uneasy (Millon & Davis, 1996, p. 261).

    Kantor (1992, pp. 36-41) notes that individuals with AvPD, as with all of the personality disorders, have a tendency to live in the past or in fantasy -- they receive too little input from the here and now. This diminished ability to pay attention results in mild memory disturbances and a characteristic immaturity. These individuals are distracted by their own extraordinary sensitivity to subtleties of tone and feeling; they are hyperalert to the meaning of emotive communication. Their thought processes are interfered with by flooding of irrelevant environmental details (Millon & Davis, 1996, p. 263).

    Individuals with AvPD behave in a stiff, shy, and apprehensive manner that is disquieting to others. The very rejection they fear may be the direct result of other people becoming impatient and uncomfortable with their unremitting tension and inability to accept that they can be a part of interaction without special guarantees of safety. In fact, people with AvPD, overtly or covertly, are seeking others to take the interpersonal risks for them; they are not able to be responsible for their own well-being socially and become a burden on the nurturing and care-taking capacity of those around them. For those who experience severe avoidant symptoms, no amount of protectiveness or gentleness can ease their fear; they will withdraw without explanation and leave behind a general bewilderment about what went wrong.

    Affective Issues

    Shame is one of the central AvPD affective experiences. Shame and self-exposure are intimately connected -- which leads to withdrawal from interpersonal connection to avoid experiencing shame (Sutherland & Frances, Gabbard & Atkinson, eds, 1996, p. 993). These individuals are anguished. They describe their emotions as a constant and confusing undercurrent of tension, sadness, and anger. Sometimes this relentless pain results in a general state of numbness. They posses few social skills and personal attributes that can lead them to the pleasures and comforts of life. They must attempt to avoid pain, to need nothing, to depend on no one, and to deny desire. They try to turn away from their awareness of their unlovability and unattractiveness (Millon & Davis, 1996, p. 265).

    Feeling capacity is normal for individuals with AvPD; it is their affective expression that is limited. Insight is present but superficial and not useful; it is seldom used for change (Kantor, 1992, p. 108). Their main affect is dysphoria, a combination of anxiety and sadness (Beck, 1990, p. 44). They are apprehensive, lonely, and tense (Sperry & Carlson, 1993, p. 332); they can experience feelings of emptiness, depersonalization (Sperry, 1995, p. 36), and excessive self-consciousness. Occasionally, individuals with AvPD lose control and explode with rage (Benjamin, 1983, p. 297).

    Defensive Structure

    Individuals with AvPD utilize fantasy to interrupt their painful thoughts. They seek to muddle their emotions because diffuse disharmony is more tolerable than the sharp pain and anguish of being themselves. They also depend on fantasy for some measure of need gratification. Other AvPD defenses include avoidance and escape. Their paramount goal is to protect themselves from real or imagined psychic pain. Fantasy and escape are all that is left because they cannot gain comfort from themselves or from others (Millon & Davis, 1996, pp. 264-265).

    Dorr (Retzlaff, ed., 1995, p. 196) also notes that individuals with AvPD can deal with their emotions only through avoidance, escape, and fantasy. When faced with unanticipated stress, they have few internal strengths available to them to manage the situation. Energy is misdirected to avoid rather than to adapt. While these individuals seek isolation out of fear of humiliation or rejection, they desire relationships and connection. That leaves them with fantasy as their primary defense; here, the use of fantasy can be seen as a variant of the general defense of denial (Kubacki & Smith, Retzlaff, ed., 1995, p. 167).

    Individuals with AvPD take rejection as an indication of personal deficiencies; they engage in a string of automatic self-critical thoughts that are extraordinarily painful. The resultant AvPD social avoidance is readily apparent. What is less obvious is the concurrent cognitive and emotional avoidance. Their dysphoria is so painful that they use activities and addictions to distract them from negative thoughts and feelings as well. They engage in wishful thinking, e.g. one day the perfect relationship or job will come along; one day they will be confident and have many friends. The patterns of cognitive, emotional, and behavioral avoidance are reinforced by a reduction in sadness and become ingrained and automatic (Beck, 1990, pp. 257-265). Meanwhile, individuals with AvPD lower their reality-based expectations and stay clear of involvement with real people (Beck & Freeman, 1990, pp. 43-44).

    Table of Contents

    Treating the Avoidant Personality Disorder

    The Avoidant Personality Disorder Coming Into Treatment

    AvPDs may enter treatment via the criminal justice system or through self-referral. If they come in on their own, they are likely to be so apprehensive that any difficulty in the intake process will precipitate withdrawal. They will respond to kindness and positive regard but any indication of irritability or annoyance on the part of reception or intake personnel may prove intolerable. In mental health settings, these individuals may be drug-seeking if they have discovered the comfort that can be obtained through chemicals. Unfortunately, their pain is so apparent that many psychiatrists are more inclined to prescribe benzodiazepines for these individuals than people with any of the other personality disorders.

    Unlike the other personality disorders in which denial, minimization, and externalization bring an illusory comfort and sense of personal justification, individuals with AvPD may well be motivated to seek change because the dynamics of their personality disorder are genuinely difficult to tolerate. They will frequently describe social and occupational problems; they will rarely have been able to develop a social network that is strong enough to help them through personal crises (DSM-IV, 1994, p. 663).

    Medication Issues

    It is recommended, for personality disordered individuals, to medicate target symptoms rather than the personality disorder itself. AvPD is quite vulnerable to the target symptom of dysphoria which is usually accompanied by mood instability, low energy, leaden fatigue, and depression. Also associated with dysphoria is a craving for chocolate and for the use of stimulants, e.g., cocaine. Many dysphoric individuals will respond to standard antidepressant medications (Ellison & Adler, Adler, ed., 1990, p. 53). Global improvement for individuals with AvPD may be possible in response to tranylcypromine, phenelzine, or fluoxetine. (Ellison & Adler, Adler, ed., 1990, p. 47)

    Anxiety, defined as an unpleasantly heightened responsivity of the autonomic nervous system to interpersonal and environmental cues may be beneficially medicated with beta blockers, MAOIs, and the triazolobenzodiazepine alprazolam (Ellison & Adler, Adler, ed., 1990, pp. 53-54). While benzodiazepines can be effective for AvPD, the use of these medications should be balanced with the these individuals' propensity for substance dependence. The newer SSRIs may be effective for the core features of AvPD: shyness, rejection sensitivity, heightened psychic pain, and distorted cognition related to self-criticism and self-effacement (Sutherland & Frances, Gabbard & Atkinson eds., 1996, p. 993).

    The specific features of personality disorders affect compliance with medication. Individuals with AvPD may be alarmed at the possibility of side effects and react with fear to the medication (Ellison & Adler, Adler, ed., 1990, p. 59) (Sperry, 1995, p. 50).

    On the other hand, anti-anxiety medication will be very appealing to individuals with AvPD. It is possible, however, that sedative-hypnotics are the clients' drug of choice and tolerance is already in place. These individuals must develop non-chemical courage and the tolerance they actually need is for interpersonal anxiety. Even if they are not already involved with minor tranquilizers, they are likely to overvalue their effects. Iatrogenic addiction is a significant concern. One psychiatrist in a major community mental health system stated emphatically that it was so painful to be avoidant that he would prefer to allow an addiction to benzodiazepines to develop than to ask these individuals to tolerate their psychological discomfort. While this position may (or may not) be understandable, addiction is not an acceptable alternative to the symptoms of AvPD. Treatment can be effective and non-addicting medications can assist with the symptoms well enough to facilitate the change process.

    Treatment Provider Guidelines

    For individuals with AvPD, developing trust in service providers is both essential and difficult. They are hypersensitive and prone to feeling criticized, judged, and injured by interpretation and confrontation in the treatment process (McCann, Retzlaff, ed., 1995, p. 146). They may well feel shame even while remaining superficially compliant with treatment. They are inclined to engage in testing behavior to see if they will be accepted and supported (Kubacki & Smith, Retzlaff, ed., 1995, pp. 167-169). Accordingly service providers must make an extra effort to establish rapport with avoidant clients. These individuals will be less likely to flee the treatment relationships if service providers are patient, nonthreatening, and sympathetic (Donat, Retzlaff, ed., 1995, p. 49). If the service providers are able to demonstrate that they are nonjudgmental, safe, and patient, individuals with AvPD will be able to form an intense and loyal treatment relationship (Benjamin, 1993, p. 305).

    Clinicians need to recognize that individuals with AvPD tend to withhold or understate information that is relevant and be alert to the AvPD infectious helplessness, lack of attentiveness and firmly held negative beliefs (Sperry, 1995, pp. 50-51). Individuals with AvPD may initially elicit over-protectiveness and then exasperation. They must be encouraged to take risks or be allowed to diminish the potential quality of their lives if they cannot tolerate necessary changes. Service providers cannot take on the clients' own responsibilities (Dorr, Retzlaff, ed., 1995, p. 197) or attempt to push them further than they are willing or able to go. These individuals can recognize that other people find relationships rewarding (Donat, Retzlaff, ed., 1995, p. 49) and they are aware of their own pain; they may be motivated enough to change but will require patience for their hesitancy, avoidant behavior, and paralyzing anxiety. Once rapport and trust are developed, service providers must then be careful not to become "interpersonal methadone" and replace avoidant individuals' need to form outside relationships (Benjamin, pp. 305-306). Clinicians can become a safe haven for these clients and actually reduce their need for interpersonal connection in their social environment.

    Service providers also need to remember that treatment progress for individuals with AvPD is usually quite slow; the process can be very frustrating for both the clients and the treatment providers (Beck, p. 280). Often, the belief that gradual change is both possible and beneficial must come from the clinicians. Individuals with AvPD are accustomed to defeat, self-deprecation, and withdrawal. They need someone else to believe in them while they begin the long process toward self-confidence and a sense of self-efficacy.

    Transference and Countertransference Issues

    Transference for individuals with AvPD is usually anxious fearfulness of the rejection, humiliation, and exasperation of the service providers.

    Countertransference involves the clinicians' reactions to the hypersensitivity and psychological fragility of these clients. They tend to elicit either overprotectiveness or excessive ambition on the part of service providers. Then, when the slow pace of discernible progress becomes frustrating, there may be an inclination for the clinicians to become the rejecting, exasperated, and judgmental people that individuals with AvPD feared they would be.

    Another possibility for countertransference is an easy acceptance of and cooperation with the safety of the therapeutic relationship against a more dangerous external world. It may be appealing to service providers to be the trusted, admired, and depended upon "good parent" that these individuals never had. Part of the efficacy of group treatment modality is to allow individuals with AvPD to develop trust in others and in themselves without seeing the service providers as their only safety in a perilous world.

    Treatment Techniques

    When assessing individuals for AvPD, the following questions have been suggested by Zimmerman (1994, pp. 116-117).

    Several approaches and modalities have been suggested for effective AvPD treatment. These include:

    1. Behavioral treatment.

      There has been significant improvement for individuals with AvPD with behavioral treatment interventions such as graduated exposure, social skills training, and systematic desensitization (Sutherland & Frances, Gabbard & Atkinson, eds., 1996, p. 991).

      The behavioral approach focuses on recognition of situations being avoided and negative, deprecatory self-statements. Anxiety management training, socialization experiences, development of communication skills, and basic assertiveness training can be quite helpful (Donat, Retzlaff, 1995, p. 49).

    2. Cognitive therapy.

      This approach effectively addresses AvPD cognitive distortions regarding their sense of competency and self-worth. As with behavior therapy, the cognitive approach assists individuals with AvPD to identify their negative self-thoughts and the origin of these thoughts. They also need to know that others struggle with similar issues and that they are not alone (Will, Retzlaff, ed., 1995, p. 98).

      If the self-talk of individuals with AvPD has become savage in its self-deprecatory intent, little progress in treatment can be achieved if this pattern is not altered. Self-statements must be clearly identified; clients should be asked specifically what they call themselves or how they refer to themselves when feeling inept, inadequate, or unacceptable. The words can be startling in their intensity and viciousness. These must be countered in the treatment process with constructive, realistic, and self-accepting statements of encouragement and affirmations directed toward self-efficacy.

    3. Interpersonal treatment.

      Interpersonal therapy helps to build the ego strength needed to recognize situations that set off regressive patterns. Individuals with AvPD need to learn about maladaptive patterns and their roots, make the decision to change, and learn new patterns. There are five categories of therapeutic response: facilitating collaboration, helping the individual learn about patterns, blocking maladaptive patterns, enabling the will to change, and teaching new patterns. (Benjamin, 1983, p. 132)

      An interpersonal focus in treatment would address the specific relationships in the individuals' past that resulted in the "burnt child" reaction to people and relationships. It would also be important to look for interpersonal experiences that have been rewarding (Craig, Retzlaff, 1995, p. 79).

    4. Support groups.

      Treatment needs to address the variation and needs of the different individuals meeting the diagnostic criteria. Individuals with AvPD who have been taught fearfulness and withdrawal by an AvPD parent are very different than those who were incest victims. For individuals who did experience incest, problem-specific groups composed of people with similar backgrounds are especially helpful (Stone, 1993, p. 357).

    5. Group therapy.

      While individuals with AvPD can benefit from cognitive, behavioral, interpersonal, or psychodynamic therapy, the confidence gained through supported social exposure is vital for significant change. Even though these clients believe themselves unable to tolerate the anxiety of the group process, they still long for relationships and need the skills that make the development and maintenance of relationships possible. Group therapy is the treatment modality of choice, but these individuals must be prepared for and supported through the entry into a group. Shame and self-doubt will make the initial group experience extremely difficult; a supportive contact with a trusted service provider to work through this process on an individual basis may be necessary for individuals with AvPD to successfully join a group.

    Treatment Goals

    For individuals with AvPD, the goal of treatment is to increase self-esteem, increase confidence in interpersonal relationships, and to de-sensitize their reaction to criticism (Sperry, 1995, p. 44). Treatment should be directed toward reinforcing a self-concept of competency. These individuals can learn to balance caution with action and to develop a tolerance for failure (Dorr, Retzlaff, ed., 1995, pp. 196-197).

    Millon (Millon & Davis, 1996, pp. 281-282) believes that the ultimate aim of therapeutic intervention is to counter the tendency for individuals with AvPD to perpetuate a pattern of social withdrawal, perceptual hypervigilance, and intentional cognitive interference. He does note, however, that these individuals often have a poor prognosis. Their habits and attitudes are pervasive and ingrained, as with all the personality disorder patterns. They are rarely in a supportive environment that could assist them to change their behavior. They are also inclined, in treatment, to reveal only that which will not cause the service provider or other group members to think ill of them.

    As with all of the personality disorders, individuals with AvPD cannot become their own personality and temperamental opposite. While they may, in fact, fantasize about becoming an outgoing, confident extrovert, the development of a more functional version of their basic personality traits can lead to a substantial improvement in the subjective experience of the quality of their lives. Oldham (1990, pp. 173-182) suggests that the more functional personality style of the avoidant personality disorder is the "sensitive personality style." These individuals are comfortable with the familiar, stay close to family and a limited number of friends, care what others think about them, are cautious and deliberate in dealing with others, and maintain a courteous, polite interpersonal reserve. Within their own homes and with friends, they are warm, giving, open and creative. The implication is that these individuals can develop rewarding relationships and live with interpersonal connectedness while not pressuring themselves to be excessively outgoing. They do not have to be extroverted to avoid isolation.

    Accordingly, it is important that treatment goals address realistic expectations for change, including confrontation of fantasies that cannot be realized and should not be part of the treatment plan. For example, one single, AvPD male client, a carpenter in his early thirties, was somewhat like Elvis Presley in his fantasies. He longed to have a Cadillac convertible, wore his hair long and slicked back, and dressed in tight blue jeans, silk shirts, and gold jewelry. Part of his fantasy was having a relationship with a beautiful, tall, blond, slender young female who would affirm his own desirability. In the meantime, a female friend that he was quite fond of but who was short, brunette, heavy, and not particularly attractive was quite interested in him. This individual was not, at the time he was in treatment, willing to release his fantasies of who he was not so that he could enjoy who he was. He described himself as lonely, frustrated, and sad. His feelings related to the longing in his fantasy version of himself. He was unable to accept and appreciate what was available to him that would allow him to be considerably less lonely.

    Table of Contents

    Dual Diagnosis Treatment:
    Treating The Addicted Avoidant Personality Disorder

    Cluster C: Incidence of Co-Occurring Substance Abuse Disorders

    Cluster C has a high incidence of co-occurring substance abuse disorders, though not as high as Cluster B (Nace, O'Connell, ed., 1990, p. 184).

    Individuals with personality disorders, due to their frequent failures in self-regulation, have an increased inclination to use drugs and alcohol as alternative solutions to life problems. This failure in self-regulation and faulty adaptation to normal stressors can usually be attributed to deficiencies or disturbances in the personality (Richards, 1993, pp. 227-240). As Freud has said, intoxicating substances keep misery at a distance and provide a greatly desired degree of independence from the external world. With the help of drugs, anyone can withdraw from the pressures of reality and find refuge in a world of their own (Khantzian, Halliday, & McAuliffe, 1990, Opening page). Individuals with AvPD are lonely, sad, and unable to find comfort either within themselves or with others. They are extraordinarily vulnerable to the seductivity of drugs and alcohol for solace, courage, and avoidance of pain. Addiction may be quite advanced with significant negative consequences in place before individuals with AvPD can begin to consider that they must give up the one reliable source of self-comfort they have in their lives.

    While Khantzian, et. al. (1990, p. 3) view the treatment of any character disorder as the road to recovery from addiction, their approach also demands a continued attention to and concern about maintaining abstinence and avoiding relapse. Addiction becomes a disorder in its own right and must be addressed directly. However, the treatment of personality disorders can lead to profound change in the personality disordered individuals' experience of self and the world, which, in turn, can positively affect recovery from addiction.

    Drugs of Choice for the Avoidant Personality Disorder

    For individuals with AvPD, drugs and alcohol provide escape/avoidance of painful feelings and the situations that elicit these feelings. Drug use assists in modulating hyperarousal and self-deprecatory thoughts. Some individuals with AvPD prefer mild hallucinogens over other drugs, perhaps because they facilitate fantasy. However, sedatives and antianxiety agents are usually the drugs of choice for most clients with AvPD (Richards, 1993, p. 269). While sedative-hypnotics calm anxiety, stimulants or PCP can provide a sense of strength or reduced vulnerability. The drug of choice for these individuals will be whatever gives them a sense of efficacy or allows them to believe that they can be attractive and effective interpersonally.

    Many individuals with AvPD also develop compulsive behaviors that relate to appearance enhancement, fantasy, and self-comfort. They may enter treatment with compulsive shopping, compulsive sexual behaviors, and eating disorders in place as well as with drug or alcohol addiction. Abstinence, to be effective, will need to address all self-destructive behaviors as well as drug and alcohol use.

    Dual Diagnosis Treatment for the Avoidant Personality Disorder

    Dual diagnosis treatment for individuals with AvPD must consider the function of their addiction, including their drug of choice, within the context of their personality psychopathology (Richards, 1993, p. 278). While these individuals may admit drug abuse, they will be inclined to refuse to acknowledge the reality or the meaning of their addiction (Richards, 1993, pp. 238-239). They gain some sense of control with their addictive behavior, despite negative consequences. The key that opened the doorway to excess for preaddicted individuals with AvPD was the good feeling that they learned to create, and repeatedly recreate, through self-determined drug-using activity (Milkman & Sunderwirth, 1987, p. 16). They have learned to feel happy by manipulating feeling states rather than by coping with external reality (Hoskins, 1989, p. 37). Or alternatively, they may be attempting to cope with external reality with chemical courage or drug-induced self-confidence. Either way, these individuals are modifying their troubled feelings without influencing their causes. Their addiction is a magical solution to the pain of life (Peele, 1985, p. 120). As such, they will be quite resistant to the loss of their drug of choice.

    Salzman (Mule, ed., 1981, pp. 346-347) believes that the inner forces that initiate and sustain addiction are immaturity, escapism, and grandiosity. New ways must be learned for dealing with feelings of powerlessness and helplessness other than compulsivity. A nonaddicted lifestyle includes an awareness that negative feelings, insoluble problems, and a sense of inadequate rewards will never disappear entirely. To move beyond addiction, individuals must be willing to tolerate the uncertainty of life and must believe they have the strength to generate positive rewards for themselves (Peele, 1985, p. 156).

    Dual diagnosis group treatment can address both the addiction issues and allow the corrective action of a positive group experience to take place for individuals with AvPD. Peers can confront unrealistic expectations, normalize many painful feelings by sharing their own, and give support for behavioral change.

    The impact of the 12 Step Groups may be powerful enough to allow individuals with AvPD to seek their strength through the recovery community rather than through addiction. However, successful integration into the 12 Step recovery process may require support and encouragement from treatment providers to assist with whatever initial negative experiences may occur and to counteract the inclination these individuals have to withdraw from and avoid anxiety-inducing interpersonal experiences.

    Confrontation usual to substance abuse treatment may defeat these individuals and overwhelm their defenses. Individuals with AvPD already know how to give up in defeat and humiliation cannot be tolerated. Confrontation should be modified and more supportive than needed for individuals with greater self-confidence .

    Abstinence should not be a prerequisite to treatment. Individuals with AvPD believe they can do very little and are inclined to define themselves as incapable of accomplishing their goals. Because they are inclined to give up, abstinence as a goal can allow service providers to bolster self-confidence for clients with AvPD through manageable treatment objectives. Small increments of change can assist these individuals to believe that they can achieve abstinence as a long-term goal.

    Table of Contents

    Sharon C. Ekleberry, 2000