Examining Avoidant Personality Disorder and Addiction

Personality disorders represent long-standing patterns of behavior and inner subjective experiences (e.g., emotions, attitudes, beliefs, etc.) that significantly depart from expectations in the individual’s culture.

These inner experiences and patterns of behavior are persistent, extremely rigid, resistant to change, and began to appear during a person’s adolescence or young adult years. They remain stable over time, and the results of these behaviors and inner feelings lead to significant personal distress or issues with functioning.

Issues with Personality Disorders Diagnoses

Clinically, the notion of personality disorders has been extant for quite some time. It has been a mainstream diagnostic category in abnormal psychology and psychiatry for decades. However, there has been some controversy regarding how the leading diagnostic organization, the American Psychiatric Association (APA), has conceptualized these disorders.

The APA specifies these disorders as being categorical and mutually exclusive separate disorders from one another; however, in practice, they share many similar symptoms, and individuals are often diagnosed with more than one personality disorder. This indicates that some of these disorders may have different manifestations of the same core issues. On the other hand, according to the current diagnostic scheme, the same personality disorder can be diagnosed in two different people yet have very different presentations, suggesting that perhaps the diagnoses are too general in nature and not specific enough.

These issues led to the hope that the latest edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) would use the new conceptualization to identify personality disorders; however, these disorders remain essentially unchanged from previous editions. This inability on behalf of APA to update their classification scheme for personality disorders is just one of the many controversies surrounding the current approach to diagnosing psychiatric/psychological disorders.

Nonetheless, the current conceptualization is still in use.  This article will discuss avoidant personality disorder and its relationship to substance use disorders.

Avoidant Personality Disorder

There are currently a total of 10 different personality disorders in the DSM-5. These disorders are grouped together into three different clusters. Each cluster contains personality disorders that share a common feature.

Avoidant personality disorder is one of three personality disorders in Cluster C: personality disorders that exhibit anxious or fearful types of behaviors.  The clinical diagnosis of avoidant personality disorder is based on seven different diagnostic criteria. The individual must meet at least four of these in order to receive a diagnosis of avoidant personality disorder. The formal diagnostic criteria will not be presented here; however, a general description that includes aspects of these diagnostic criteria follows.

• The essential presentation of avoidant personality disorder is one where the person demonstrates a very persistent and all-encompassing pattern of feeling inadequate, being overly sensitive to real or perceived negative evaluations, and engaging in withdrawal from activities that involve interpersonal contact with other people.
• Individuals with avoidant personality disorder are extremely sensitive (to the point of being hypersensitive) to criticism, and to perceived or anticipated criticism. They often mistake benign comments or even compliments as critical evaluations.
• These people typically avoid any activity where they will socialize with others and have extreme difficulty making new friends due to fears of disapproval, criticism, or rejection.
• They are resistant to getting involved with others, and they are certain that others will like not them. These individuals often view themselves as being inept, socially inadequate, personally unappealing, and even inferior to other people.
• They tend to stick to routines and well-established patterns of behavior and avoid engaging in new activities due to fear of being criticized or embarrassed.

While many people might be able to think of individuals who somehow satisfy some of the above descriptions, it is important to understand that when this type of behavior presents as a personality disorder, it is invasive, persistent, and rigid. This means that the individual exhibits these behaviors in nearly every situation they encounter nearly every day, and these patterns of behavior been established since childhood, adolescence, or young adulthood. They are very rigid and invade every aspect of the person’s life, and they are extremely resistant to change. Behaviors observed and personality disorders do not represent normal variations in feelings and behaviors observed in most people. The behaviors lead to significant distress or issues with functioning in these people nearly every day.

It is also important to note that avoidant personality disorder is not simply extreme shyness or a social phobia. The key components of avoidant personality disorder are the rigid and fixed beliefs that the individual will be negatively evaluated or humiliated in the context of being with others. Social phobias often relate to specific social situations, such as giving a speech in public or performing in public. They are not the pervasive overall avoidance of any type of interpersonal reaction. Shyness refers to a personality trait that is often prone to remitting once an individual becomes familiar and comfortable with others. Individuals with avoidant personality disorder do not become familiar and comfortable with the majority of people they encounter, no matter how much exposure they get to them.

Avoidant personality disorder appears to be diagnosed equally in males and females. It occurs in about 2.4 percent of the general population, and it may often be misdiagnosed in individuals who are having difficulties with becoming acculturated to new ways of life, such as immigrants and refugees. Avoidant personality disorder has no formal identified cause. It is believed to occur as a result of a combination of inherent and environmental factors.

Other Characteristics of Avoidant Personality Disorder

Research investigating the day-to-day behaviors of individuals with personality disorders has determined some interesting observations regarding how people diagnosed with avoidant personality disorder view and explain the world. Some of these tendencies follow:

• The use of statements that include the words always or never. For example, individuals with avoidant personality disorder might repeat statements, such as, “I can never do that as good as someone else,” or “Other people always humiliate me.”
• Individuals with avoidant personality disorder are experts at using a cognitive bias known as the confirmation bias. In this form of thinking, individuals are biased toward paying attention to what they expect and what they already believe, and rarely except information that challenges or is inconsistent with their beliefs.
• People with avoidant personality disorder tend to catastrophize situations that involve social interactions. This means that they expect worst-case scenarios to occur in any situation where they are required to interact with others. These worst-case scenarios involve them being criticized, humiliated, or devalued.
• People with avoidant personality disorder tend to engage in self-fulfilling prophecies. This means that they have certain negative expectations regarding interactions with others. When they do interact with others, they often act in a manner to elicit behavior from others that is consistent with these expectations.
• Obviously, people with an avoidant personality disorder tend to have a negative view of themselves and their ability to function even at an adequate level in social situations.

Like all personality disorders, individuals diagnosed with avoidant personality disorder are very likely to be diagnosed with other personality disorders, depression, anxiety, and substance abuse.

According to APA, the personality disorders that most commonly at co-occur with avoidant personality disorder are:

• Paranoid personality disorder, where individuals are persistently suspicious of others
• Dependent personality disorder, where individuals become overly dependent on one or very few individuals to satisfy their needs
• Obsessive-compulsive personality disorder, which is different than obsessive-compulsive disorder: In this disorder individuals are very rigid regarding routine, inflexible regarding approaches to goals, and often preoccupied with strict control of events that occur within their sphere of influence.

Avoidant Personality Disorder and Substance Abuse

Like all personality disorders, individuals with avoidant personality disorder are susceptible to developing co-occurring substance use disorders. These individuals can develop substance use disorders to any class of drugs; however, substances of choice for individuals with avoidant personality disorder are typically drugs that deaden anxiety and their tendency toward negative appraisals, such as alcohol, marijuana, and other central nervous system depressants, including benzodiazepines, narcotic medications, and sedatives.

Other individuals with avoidant personality disorder may turn to drugs that instill confidence or a sense of invulnerability, such as cocaine or other stimulants, including Ritalin, Adderall, and even crystal meth. Some individuals with avoidant personality disorder may be prone to developing substance use disorders to psychedelics or hallucinogenic drugs due to their tendency to want to escape and to fantasize.

Treatment for Avoidant Personality Disorder

The treatment for personality disorders is often very complicated because these individuals typically do not refer themselves to treatment. They are often referred to treatment by others who are concerned about their behaviors. This is also true for avoidant personality disorder where individuals will normally shun interpersonal reactions and therefore will not typically approach other individuals for help. Often, individuals with personality disorders view everyone else as having the problem and do not view themselves as having issues.

When individuals are placed in treatment protocols for avoidant personality disorder, the treatment method of choice is most often some form of Cognitive Behavioral Therapy that addresses the person’s irrational beliefs about others, particularly about issues with criticism and negative evaluations. Skilled therapists work with individuals to identify their core beliefs, help these individuals test these beliefs regarding their validity in the real world, and then help them cognitively restructure their dysfunctional beliefs in a manner more consistent with reality to allow a more functional approach to living.

Therapists may also use exposure techniques, where individuals are actually exposed to anxiety-provoking or feared situations in conjunction with the development of stress reduction and relaxation training. This type of treatment requires very advanced training, patience, and persistence. Other forms of therapy have also been used to treat avoidant personality disorder, such as psychodynamic therapy and interpersonal therapy.

Therapy will typically begin in individual outpatient sessions; however, if the person can be coaxed into group therapy, this can make the treatment even more effective. Cognitive Behavioral Therapy is also the therapy of choice for addressing issues with substance abuse and substance use disorders.

There are no medications specifically designed to treat avoidant personality disorder; however, selective serotonin reuptake inhibitors, a class of antidepressant medications, have been demonstrated to assist individuals with avoidant personality disorders deal with low-level chronic anxiety and become more open to positive evaluations of themselves. Individuals with avoidant personality disorder may also be treated with certain antianxiety medications, such as benzodiazepines (e.g., Xanax, Valium, Ativan, Klonopin, etc.); however, individuals who have a co-occurring substance use disorders need to use these under the strict supervision of a doctor. Most often, treatment involves a combination of medications and therapy.