Treating the Avoidant Personality Disorder

The Avoidant Personality Disorder Coming Into Treatment

Avoidant Personality Disorders 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 Avoidant Personality Disorder 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. Avoidant Personality Disorder 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 Avoidant Personality Disorder 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 Avoidant Personality Disorder, 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 Avoidant Personality Disorder: 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 Avoidant Personality Disorder 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 Avoidant Personality Disorder. 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 Avoidant Personality Disorder. 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 Avoidant Personality Disorder, 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 Avoidant Personality Disorder will be able to form an intense and loyal treatment relationship (Benjamin, 1993, p. 305).

Clinicians need to recognize that individuals with Avoidant Personality Disorder tend to withhold or understate information that is relevant and be alert to the Avoidant Personality Disorder infectious helplessness, lack of attentiveness and firmly held negative beliefs (Sperry, 1995, pp. 50-51). Individuals with Avoidant Personality Disorder 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 Avoidant Personality Disorder 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 Avoidant Personality Disorder 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 Counter transference Issues

Transference for individuals with Avoidant Personality Disorder 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 Avoidant Personality Disorder 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 Avoidant Personality Disorder 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 Avoidant Personality Disorder, the following questions have been suggested by Zimmerman (1994, pp. 116-117).

• Do you try to avoid work that involves contact with a lot of people?
• Are you afraid people will criticize or reject you?
• Have you ever turned down a promotion or a job because it would have required increased contact with people?
• Do you avoid getting to know someone because you are worried they may not like you? Has this affected the number of friends you have?
• Even in a close relationship, do you sometimes not share your thoughts or feelings because you are afraid the other person might put you down?
• If you are criticized, do you think about it for hours, or even days?
• Does it seem harder for you than for other people to carry on a conversation with someone you have just met?
• Do you feel inadequate in social situations?
• Do you feel like you are not as interesting or fun as other people?
• How do you think you relate to other people? If poorly, why do you think that is?
• Would you describe yourself as someone who is willing to take risks or take on new activities or would you prefer to play it safe and remain with the familiar?

Several approaches and modalities have been suggested for effective Avoidant Personality Disorder treatment. These include:

1. Behavioral treatment.
   There has been significant improvement for individuals with Avoidant Personality Disorder 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 Avoidant Personality Disorder cognitive distortions regarding their sense of competency and self-worth. As with behavior therapy, the cognitive approach assists individuals with Avoidant Personality Disorder 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 Avoidant Personality Disorder 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 Avoidant Personality Disorder 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 Avoidant Personality Disorder who have been taught fearfulness and withdrawal by an Avoidant Personality Disorder 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 Avoidant Personality Disorder 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 Avoidant Personality Disorder to successfully join a group.

Treatment Goals

For individuals with Avoidant Personality Disorder, 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).

As with all of the personality disorders, individuals with Avoidant Personality Disorder 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, Avoidant Personality Disorder 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.

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 Avoidant Personality Disorder 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 Avoidant Personality Disorder 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 Avoidant Personality Disorder, 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 Avoidant Personality Disorder 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 Avoidant Personality Disorder (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 Avoidant Personality Disorder 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 Avoidant Personality Disorder 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 Avoidant Personality Disorder 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 Avoidant Personality Disorder. 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 Avoidant Personality Disorder 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 Avoidant Personality Disorder 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 Avoidant Personality Disorder 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 Avoidant Personality Disorder through manageable treatment objectives. Small increments of change can assist these individuals to believe that they can achieve abstinence as a long-term goal.

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Reviewed: 04/2006