Cluster C: Avoidant Personality Disorder

The Dual Diagnosis Pages
home

29 March, 2000

Cluster C: AVOIDANT PERSONALITY DISORDER (AvPD)

Mental Health Issues Treatment Issues AvPD & Addiction:
Dual Diagnosis Treatment Issues

Essential Feature: A pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation (DSM-IV™, 1994).
Self Image: Socially inept, anxious, incompetent, unattractive, refer to self with contempt (Beck, Millon).
View of Others: Assumed to be critical, betraying, uninterested, demeaning, and humiliating (Beck, Millon). Believe that others will treat them as they have been treated in the past.
Relationships: Avoid social contact out of fear of rejection; wish for acceptance but cannot tolerate the anxiety generated by interaction; "lonely loners" (Benjamin, Oldham).
Authority Issues: Fear authority figures; vulnerable to humiliation. Will tend to be compliant but will also withhold significant information.
Behavior: Seem awkward, uncomfortable, timid, shy, distrustful, apprehensive, fearful, and tense. They impose a strain on others when interacting (Millon, Sperry).
Affective Issues: Feel lonely, unwanted, fearful, and different; dysphoria, emptiness and depersonalization (Millon, Benjamin, Sperry).
Defensive Structure: Distracted and preoccupied, hyperalert, acutely perceptive observers; withdrawn and maintain low expectations; socially, cognitively, and emotionally avoidant (Millon, Beck).
The AvPD Coming Into Treatment: AvPDs may enter treatment via the criminal justice system or through self-referral. AvPDs are reluctant to disclose very much; they are hypersensitive to perceived degradation and attack and will easily be injured (Benjamin).
Medication Issues: Extreme social anxiety may be responsive to MAOIs or beta-blockers (Sperry). Psychotropic medication may be useful depending on presenting symptoms. If the AvPD is mixed with panic attacks or social phobia with concomitant physical symptoms, beta-blockers or benzodiazepines will be helpful (Stone, 1993). However, addicted AvPDs are likely to overvalue and actively seek minor tranquilizers. Sedative-hypnotics may be the client's drug of choice with tolerance already in place. Iatrogenic addiction is a significant concern.
Treatment Provider Guidelines: Treatment progress is usually quite slow; the process can be very frustrating for the treatment provider (Beck).
Treatment must be supportive and non-demeaning. Avoidant individuals are intensely sensitive and prone to shame and defeated withdrawal. Once trust has been developed, clinicians must take care not to become "interpersonal methadone" (Benjamin) and remove the impetus these individuals have to form relationships external to the treatment process.
Countertransference Issues: Clinicians will be tempted to be either overprotective or overly ambitious. Care must be taken to avoid infectious helplessness and concomitant exasperation (Sperry). Clinicians must be prepared to accept clients' decision not to change.
Treatment Techniques: AvPDs can benefit from behavioral, cognitive, interpersonal, and psychodynamic treatment. The treatment modality of choice is group; support may be needed for AvPDs to successfully manage their initial negative response to the group experience.
Treatment Goals: Treatment goals include increasing self-esteem and interpersonal self-confidence; to de-sensitize AvPDs to criticism (Sperry); reduce anxiety; alter self-talk; enhance socialization skills; and assist participation in groups.

Incidence of Co-Occurring SA Disorders: Cluster C has a high incidence of co-occurring substance abuse disorders, though not as high as Cluster B (Nace).
AvPD Drugs of Choice: No single pattern of substance use or abuse can be identified for any of the personality disorders.
AvPDs will seek both sedative-hypnotics for anxiety and stimulants or PCP that provide a sense of strength or reduced vulnerability. Some AvPDs prefer hallucinogens for facilitation of fantasy (Richards).
Compulsive behaviors may include shopping for self-adornment (appearance enhancement), fantasy, and eating. Look for a co-occurring body dysmorphic disorder.
Dual Diagnosis Treatment: These individuals are vulnerable to substance use that reduces interpersonal vulnerability or eases social paralysis. Drugs or alcohol may give AvPDs a sense of efficacy; when using, AvPDs believe they can spend time with people; they can be attractive and effective interpersonally. So, if there is chemical relief from disconnection with others, treatment will hardly be an attractive alternative.
Addiction for AvPDs provides escape and avoidance of painful feelings or situations. Modulation of hyperarousal and of self-deprecatory thoughts is a prominent function of AvPD addiction (Richards).
Dual diagnosis groups can both address addiction issues and allow the corrective action of a positive group experience. 12-Step Groups could be a significant assist in the recovery process by connecting AvPDs to others who support abstinence and provide interpersonal contact.
Confrontation usual to substance abuse treatment may defeat these individuals and overwhelm their defenses. Humiliation cannot be tolerated. Confrontation should be modified and more supportive than needed for individuals with more self-confidence.
Abstinence should not be a prerequisite to treatment. AvPDs believe they can do very little. They are inclined to give up. Abstinence as a goal can allow service providers to bolster AvPDs' self-confidence through manageable treatment objectives.

Top of Page

Cluster C: AVOIDANT PERSONALITY DISORDER (AvPD)
Mental Health Issues	Treatment Issues	AvPD & Addiction: Dual Diagnosis Treatment Issues
Essential Feature: A pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation (DSM-IV™, 1994). Self Image: Socially inept, anxious, incompetent, unattractive, refer to self with contempt (Beck, Millon). View of Others: Assumed to be critical, betraying, uninterested, demeaning, and humiliating (Beck, Millon). Believe that others will treat them as they have been treated in the past. Relationships: Avoid social contact out of fear of rejection; wish for acceptance but cannot tolerate the anxiety generated by interaction; "lonely loners" (Benjamin, Oldham). Authority Issues: Fear authority figures; vulnerable to humiliation. Will tend to be compliant but will also withhold significant information. Behavior: Seem awkward, uncomfortable, timid, shy, distrustful, apprehensive, fearful, and tense. They impose a strain on others when interacting (Millon, Sperry). Affective Issues: Feel lonely, unwanted, fearful, and different; dysphoria, emptiness and depersonalization (Millon, Benjamin, Sperry). Defensive Structure: Distracted and preoccupied, hyperalert, acutely perceptive observers; withdrawn and maintain low expectations; socially, cognitively, and emotionally avoidant (Millon, Beck).	The AvPD Coming Into Treatment: AvPDs may enter treatment via the criminal justice system or through self-referral. AvPDs are reluctant to disclose very much; they are hypersensitive to perceived degradation and attack and will easily be injured (Benjamin). Medication Issues: Extreme social anxiety may be responsive to MAOIs or beta-blockers (Sperry). Psychotropic medication may be useful depending on presenting symptoms. If the AvPD is mixed with panic attacks or social phobia with concomitant physical symptoms, beta-blockers or benzodiazepines will be helpful (Stone, 1993). However, addicted AvPDs are likely to overvalue and actively seek minor tranquilizers. Sedative-hypnotics may be the client's drug of choice with tolerance already in place. Iatrogenic addiction is a significant concern. Treatment Provider Guidelines: Treatment progress is usually quite slow; the process can be very frustrating for the treatment provider (Beck). Treatment must be supportive and non-demeaning. Avoidant individuals are intensely sensitive and prone to shame and defeated withdrawal. Once trust has been developed, clinicians must take care not to become "interpersonal methadone" (Benjamin) and remove the impetus these individuals have to form relationships external to the treatment process. Countertransference Issues: Clinicians will be tempted to be either overprotective or overly ambitious. Care must be taken to avoid infectious helplessness and concomitant exasperation (Sperry). Clinicians must be prepared to accept clients' decision not to change. Treatment Techniques: AvPDs can benefit from behavioral, cognitive, interpersonal, and psychodynamic treatment. The treatment modality of choice is group; support may be needed for AvPDs to successfully manage their initial negative response to the group experience. Treatment Goals: Treatment goals include increasing self-esteem and interpersonal self-confidence; to de-sensitize AvPDs to criticism (Sperry); reduce anxiety; alter self-talk; enhance socialization skills; and assist participation in groups.	Incidence of Co-Occurring SA Disorders: Cluster C has a high incidence of co-occurring substance abuse disorders, though not as high as Cluster B (Nace). AvPD Drugs of Choice: No single pattern of substance use or abuse can be identified for any of the personality disorders. AvPDs will seek both sedative-hypnotics for anxiety and stimulants or PCP that provide a sense of strength or reduced vulnerability. Some AvPDs prefer hallucinogens for facilitation of fantasy (Richards). Compulsive behaviors may include shopping for self-adornment (appearance enhancement), fantasy, and eating. Look for a co-occurring body dysmorphic disorder. Dual Diagnosis Treatment: These individuals are vulnerable to substance use that reduces interpersonal vulnerability or eases social paralysis. Drugs or alcohol may give AvPDs a sense of efficacy; when using, AvPDs believe they can spend time with people; they can be attractive and effective interpersonally. So, if there is chemical relief from disconnection with others, treatment will hardly be an attractive alternative. Addiction for AvPDs provides escape and avoidance of painful feelings or situations. Modulation of hyperarousal and of self-deprecatory thoughts is a prominent function of AvPD addiction (Richards). Dual diagnosis groups can both address addiction issues and allow the corrective action of a positive group experience. 12-Step Groups could be a significant assist in the recovery process by connecting AvPDs to others who support abstinence and provide interpersonal contact. Confrontation usual to substance abuse treatment may defeat these individuals and overwhelm their defenses. Humiliation cannot be tolerated. Confrontation should be modified and more supportive than needed for individuals with more self-confidence. Abstinence should not be a prerequisite to treatment. AvPDs believe they can do very little. They are inclined to give up. Abstinence as a goal can allow service providers to bolster AvPDs' self-confidence through manageable treatment objectives.