Co-dependency: when caring becomes a disease

1. Co-dependency:when caring becomes a disease Yana M. Van Arsdale, MD, PhD

2. Clinical case – ID: • 48 y/o SCM • Hx Adult ADHD, treated sporadically • Self referred to out-Pt Psychiatry clinic at MSU/KCMS after episode of violent behavior and suicide attempt • CC: “I have to learn how to manage my anger”

3. HPI: • The patient suffers from significant difficulties to sustain attention, concentrate, read, follow directions • He is restless and fidgety all the time, with prominent rocking movements • He fails to complete tasks • Symptoms re-appeared since the Pt did not take Adderall for the last week, run off medication

4. HPI – cont. • The Pt reported lost trust in all people after his fiancee of four years denied his rights towards any community property, • …feeling like a failure • …feeling confused about who he is and where is he going with his life • …feeling hurt b/c others did not recognize his efforts to do more than his share

5. HPI – cont. • The patient described himself as giving, caring and loving person, • …who usually avoids arguments and keeps quiet • …cares about his partners’ lives more than they care about him • …does his best to hold on to a relationship • ...feels inferior towards others

6. HPI – cont. • The Pt doubted his ability to be who he wants to be • He reported difficulties expressing his true feelings to others, including anger • …difficulties adjusting to change • …difficulties to make decisions and to move on • …always worrying about others’ opinions of him

7. HPI – cont. • The Pt reported trouble saying “no” when asked for help • …feeling overwhelmed b/c so many things going at once • …feeling guilty and ashamed most of the time • …fear of others’ anger • …trying to make others happy but not getting much in return

8. Psychiatric Hx • Since early childhood – hyperactivity, attention deficit, impulsivity • Neglect by biological parents • Emotional and physical abuse by step father, who suffered from alcohol abuse • 10 y/o – sexual abuse by uncle • 38 y/o – first Dx ADHD by PCP, various medications trials. Good response only to Adderall 180 mg/day. • 42 y/o – first in-Pt Tx for a week at 1N at Borgess after wife had a miscarriage and asked for divorce. Cried all the time, was depressed, suicidal. No medications.

9. Psych. Hx – cont. • F/u with Pine Rest Clinic, trials of medications others than Adderall with no improvement • 46 y/o – in-Pt Tx at KPH after episode of violence towards fiancee and suicide attempt to shoot himself with a gun. Admission Dx “Bipolar DO, hypomanic episode”. D/ch Dx “Dysthymic DO” • F/u admission to Hope Center. Dx “Adult ADHD. Adjustment DO. R/o Dysthymic DO. Cluster C personality DO (dependency, avoidance features)”. Adderall re-started. F/u with PCP.

10. Medical Hx • Obesity • Hypertension • Hyperlipidemia • Hx kidney stones and lithotripsy • Hx IBS • NKDA

11. Addiction Hx • Alcohol – on rare social occasions. The Pt reports being very sensitive to alcohol even in low doses. • Marijuana – Hx until 30 y/o, helped with anxiety. Sober now. • Nicotine – 1/3 pack/ day until recently. • Caffeine – 1-3 cups cause sedation, after 5th cup – attention and concentration improve. • Denies illicit drugs abuse.

12. Family Hx • Mother attempted suicide through OD medications. Quiet, emotionally unavailable person. Tolerated physical and emotional abuse from Pt’s stepfather. • Father suffered from Alcohol Dependency, died young. Emotionally unavailable, unassertive. • Sister attempted suicide, suffers from Bipolar DO • Majority of relatives suffer from Alcohol Addiction

13. Social Hx • Lives with his mother and sister • Drummer in a nightclub music band until recently • Employed in flooring business, part-time • Helps to restore old collectable cars, for cash • Helps relatives in construction work, on occasions

14. Social Hx – cont. • Worked as a musician since age 13, just like his father and brothers • 9 grades of educations, poor academic performance • Never had any professional license, despite several vocational skills • Was deceived by other construction workers on several occasions, working under their license

15. Social Hx – cont. • 15 y/o – left his family. Lived with a women 10 years older. Supportive passionate relationship • 25 y/o – marriage of three months; “mistake” • 34 y/o – marriage of eight years. Wife was emotionally distant. She completed a master’s degree in psychology during marriage. “Suddenly” divorced the Pt after having miscarriage.

16. Social Hx – cont. • 40 y/o – severe distress over older brother’s death from DM complications. Brother was the closest friend/relative, parental figure and role model • Separation with each women especially ex-wife and fiancee was experienced as severe emotional trauma • Never had children, always wanted them • Difficulty with social contacts with strangers or maintaining superficial relationships • All close relationship with deep emotional involvement and attachment

17. Social Hx – cont. • 42 y/o – living together with J. for four years; intent to marry. She was passionate, took initiative in relationship, helped with grief over divorce and fetal demise • She completed her master’s degree in psychology, as well, while the Pt built their house. • They bought a few pieces of land together, however the Pt did not complete any documents, stating that he “trusts her” b/c of love

18. Social Hx – cont. • 46 y/o – J. denied the Pt’s right toward any community property, including the house the Pt built “from scratch” and land • The Pt was very angry and became violent, “driven by impulses” • He was arrested after staying 7 days barricaded in his bedroom with a gun in his mouth

19. Legal Hx • Probation for domestic violence with J. • No previous Hx. Have never been violent before

20. Medications • Adderall 60 mg PO at morning, 40 mg PO at noon, at 3 p.m. and at 6 p.m. • Norvasc 15 mg PO BID. Samples given at church. No PCP

21. Developmental Hx • 2 y/o – earliest memory about divorce and fighting between parents • 10 y/o – did not disclose episode of sexual abuse • Since 4 y/o – emotionally traumatized by stepfather abusing mother. Did not voice objections, considered that violence might become even worse, kept walking away

22. Develop. Hx – cont. • Was restless, hyperactive, anxious child, with difficulty sustaining attention, easily upset • All 11 siblings were emotionally close • 15 y/o – could not tolerate parents’ abusive relationship; moved out

23. MSE • Pleasant, engaging, cooperative, articulate • Soft spoken • Listens attentively but effortful • Restless, fidgety, rocking in the chair, shaking legs • Looks sad, but denies feeling depressed • Affect constricted

24. MSE – cont. • Immature statements, low self esteem • Good insight • No signs of depression or psychosis • Transient anxiety

25. Course of Tx • Within 2 months ADHD symptoms improved significantly; cont. Adderall 180 mg/day • Individual Psychotherapy: supportive, CBT, psychodynamic – for 15 months • Group therapy – denied by insurance company • Current GAF 70, overall improved relationships • Does not feel ready yet for meaningful intimate relationship, wants to work “harder” in psychotherapy

26. Definitions • Co-dependency / codependence • Dependency • Interdependency

27. Codependency, original concept • Behaviors people develop from living with a substance abuser • The term was developed in the late 1970s • Addiction literature referring to the wives of men who abuse alcohol

28. Codependency, more recent concept • Dysfunctional style of relating to others (Irwin, 1995) • Extreme focus on relationships, caused by a stressful family background, like alcoholism, mental or physical chronic illness in parent (Fisher, Spann & Crawford, 1991 • Personality trait found within members of chemically dependent families, that creates sufficient dysfunction to warrant the diagnosis of Mixed Personality Disorder (Cermak, 1986)

29. Codependency, modern concepts • Progressive disease manifested as an unconscious effort to keep repressed pain at bay, • …brought by child abuse/neglect • …caretaking through keeping the loved one addicted in order to gain a sense of self worth (Westermeyer, 2005)

30. Codependency, modern concepts • Emotional and behavioral condition that affects an individual’s ability to have a healthy, mutually satisfying relationship (National Mental Health Association, 2005) • “Relationship Addiction”, one-sided, emotionally destructive and/or abusive relationship • Behavior learned by watching and imitating other family members who display codependency

31. Codependency, modern concept • A set of maladaptive, compulsive behaviors learned by family members in order to survive in a family which is experiencing great emotional pain and distress (www, 2005)

32. Sources of great emotional pain • Chemical dependency • Chronic mental / physical illness • Physical / emotional / sexual abuse • Divorce / separation / death of loved one • Hypercritical / non-loving environment

33. Codependency features • Tendency to get involved in relationships with unreliable, needy, emotionally unavailable partner • Attraction to persons who want to have power over another people (“chemistry”) • Attempts to control relationship without addressing own needs or desires • Chronic unfulfillment • People with healthy boundaries are not likely to be involved with codependent person

34. Codependency signs & symptoms • Controlling behavior towards oneself and others • Caretaking behavior, boundary distortions • Avoidance of feelings • Intimacy problems • Hypervigilence, mistrust • Depression, anxiety • Denial, projection, projective identification, rationalization, supression • Somatoform symptoms, compulsive behavior

35. Dramatic outbursts • Constriction of undesirable emotions • Depersonalization or dissociation • Unexperienced feelings are build up over time • Any incident can trigger an explosion • Inappropriately intense compulsive exposure of feelings

36. Interdependency • Natural and healthy behaviors that are mutual, fulfilling and unrelated to addiction or abuse • Socially acceptable and encouraged • Sense of self remains relatively unaffected • Examples: gender distributed roles in a family between parents

37. Dependency (pathological) • Excessive need to be taken care of • … that leads to submissive and clinging behavior • … and fear of separation • Quick and indiscriminative attachment to another person • Passivity, allowing others to take initiative and take responsibility

38. Treatment approach / goals • Team work • Boundary setting • Learning assertiveness, listening, and communications • Breaking denial system • Awareness of non-helpful actions / behaviors • Uncovering feelings and covering them again • Developing new healthier coping skills

39. Tx modalities • Individual therapy • Family therapy • Group therapy • Psychopharmacotherapy • Education • Self-help groups (CODA, ACA)

40. Can you “care too much”…and be happier than you are now?

41. 50-80% mental health providers have not addressed their own codependency issues (NMHA, 2005; Driscoll, 2004) Maybe it’s okay to “care too much?