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
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
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
Table of Contents
Sharon C. Ekleberry, 2000